New Patient Request - Miners Colfax Medical Center 2026

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 as this information is crucial for your medical records.
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 'YES', indicate how you would like to schedule your appointment.
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, ensure all signatures are completed where indicated before submitting the form.

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