New Patient Request - Miners Colfax Medical Center 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Patient Name, Date of Birth (DOB), and Age in the designated fields. Ensure accuracy for proper identification.
3. Fill in your Primary Phone Number and an Alternate Phone Number, which is required for contact purposes.
4. Select your Requested Provider and, if applicable, provide the name of your Referring Provider or previous Primary Care Physician (PCP).
5. In the Notes section, add any additional information that may assist the provider in understanding your needs.
6. For provider use, check the appropriate box regarding medical records request and scheduling. If scheduling is needed, indicate preferences for timing.
7. Complete the Initial Evaluation Questionnaire by providing details about allergies, past medical history, surgical history, family medical history, and personal/social history.
8. Finally, review all entries for accuracy before saving or submitting your form through our platform.

Start filling out your New Patient Request today using our platform for a seamless experience!