---Cambridge, MDEaston, MDPocomoke City, MDNorth Salisbury, MDSouth Salisbury, MDWest Ocean City, MD
How did you hear about us?:
FamilyFriendRelativePrimary Care PhysicianTV CommercialEmployerDelmar billboardS Curve BillboardChincoteague billboardNew Church billboardWebsite SearchPrevious PatientOther
What are you being seen for today?:
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Include any extension (if required.)
You must provide at least one of the above three phone numbers.
Which is your preferred phone?:
If we cannot get ahold of you, is it ok if we leave a voicemail?:
American IndianAsianBlack/African AmericanNative Hawaiin/Pacific IslanderWhiteDeclined
Hispanic or LatinaNot HispanicDeclined
Employer Contact Name (if work-related injury):
Employer Contact # (if work-related injury):
Check this box if you are NOT the patient listed above and are filling this form out for another person.
Name of Card Holder (Subscriber) (if different than patient):
Sex (if different than patient):
Policy Holder Address (if different than patient):
Relationship To Card Holder:
Employer (if different than patient):
Birthdate (if different than patient):
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Do you have secondary insurance? YesNo
Workers Compensation Carrier (if work-related injury):
Claim # (if work-related injury):
WC Adjustor (if work-related injury):
Adjustor Phone # (if work-related injury):
Primary Care Physician (PCP):
Note we will fax a copy of the encounter note from today’s visit to your PCP
Please indicate individual (aside from yourself, if not minor), if any, authorized to speak with staff from Your Docs In regarding the patient’s evaluation, diagnosis, treatment and billing.
Desired Time To Be Seen:
Please enter a time (i.e. 4:00 pm) that you would like to be seen. NOTE: The desired time is NOT guaranteed for a walk-in clinic and does not move you to the front of the line.
Enter your initials to represent your signature.
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