Getting to Know You...

New Patient Application

Thank you for your interest in Hastings Internal and Family Medicine! We are a “Patient Centered Medical Home,” dedicated to the best possible health of every patient regardless of age, race, gender, disability or health status. We look forward to the opportunity to serve you!

Completion of this form does not guarantee acceptance into the practice, and does not create a provider-patient relationship. Information you submit will be shared only with your permission.

Pharmacy checks are completed for all new patients to verify history of scheduled medication use.

Hastings Internal and Family Medicine does not participate with all insurance plans.

If you prefer, a printable version of this application is available HERE, or pick one up at our office.

First Name

M.I.

Last Name

Date of birth

Street address

City

State

Zip code

Cell Phone

Home Phone

Who referred you to our practice?

Why are you looking for a new medical provider?

Who is your previous primary care provider?

Which specialists have you seen in the past 12 months?

Which hospitals have you visited in the past 12 months?

How many times have you visited the ED in the past 12 months?

List all of your current medical problems

List all your medications and doses – (include prescriptions, over-the-counter meds and supplements):

List previous surgeries, with approximate dates

Who assists you with your healthcare needs (if anyone)?

If there was one most important health problem we could help you with, what would it be?

Insurance information

Employer

Primary insurance name

Primary policy holder's name and date of birth

Primary insurance policy #

Primary insurance group #

Secondary insurance name

Secondary policy holder's name and date of birth

Secondary insurance policy#

Secondary insurance group #

By clicking the Submit Application button, I acknowledge that I have read and understand the application information above.

Thank you for taking the time to complete this form. Patient applications will receive a response by phone within 5 business days.