Parent 1 *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent 2

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Primary Phone Number *

(###)

###

####

Primary Mailing Address *

P.O. Boxes are fine :)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which of the following are you looking for? *

Seeking to establish primary care for the first time

Seeking to switch primary care

Seeking a second opinion

Seeking specialty care for a specific issue

May we have your consent to request and review your previous records or those of your children? *

By selecting "yes" below you are providing your consent for us to request pertinent medical records on your behalf to review and prepare to meet you. This helps us optimize the care we provide and give you a personal, effective experience. We will only request records for items which pertain to or affect the care we provide for you.

Yes, I give consent for you to request pertinent health records from my previous provider

No, I do not give my consent to request previous records.

Not applicable. There are no previous records to obtain