New Patient Registration

Thank you for your interest in New Medical Health Care. Please fully complete the New Patient Registration form below, and a member of our team will be in touch soon. If you have any questions, please don’t hesitate to give us a call at 316-773-1212.

If you would prefer to download the form, and submit it via email, you may download the form by clicking the button below:


New Patient Information

Last Name *

Date of Birth *

Email Address *

Home Phone Number

Cell Phone Number

Street Address *

City *

State *

Zip Code *

Responsible Party's Name, if patient is a minor

Relationship


Insurance Information

Self-Pay: *
YesNo, I have Insurance

Primary Insurance Co.

Claim Address

ID Number

Group Number

Subscriber's Name

Date of Birth

Secondary Insurance Information (if necessary)

Seconday Insurance Co.

Claim Address

ID Number

Group Number

Subscriber's Name

Date of Birth


How can New Medical help you?

Who are you requesting to see at our clinic? *

Reason for Appointment/Current Health Concerns*

New Medical Health Care is a primary care clinic. We cannot effectively coordinate care if you receive treatment from another PCP outside of our clinic. All requests are subject for review of the Kansas Prescription Drug Monitoring Program (K-TRACS).

Additional Comments/Questions

Insurance Card (please include a copy of front and back)

Please allow 24-48 hours to process your request

Ready to Schedule an Appointment?