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New Patient Intake Form

Your privacy matters. The information you provide is used by our care team to prepare for your care and

will be handled according to our privacy and security practices.

Let’s Get You Ready for

Your First Visit

Please complete this secure new patient intake form so our care team can prepare your chart, review your health history, and make your first visit as smooth as possible.

First Name *

Last Name *

What is your gender identity?

Address

Street Address *

City *

State *

Postal Code *

Phone *

Email *

Date of birth

I consent to receiving appointment reminders, care instructions, and general health communications via standard (non-encrypted) text message and/or email. I understand that these channels may not be fully secure and accept any associated risk.

Please upload a current photo of yourself. (Head and shoulders only) *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Please upload a copy of your picture ID. *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Please upload a copy of your insurance card, front and back, if applicable. *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 4 Files )

Do you have any allergies? *

Please list any current medical conditions. *

Please list any past surgeries. *

Please list your current prescription medications, including dosage and how often you take them. *

Please list any current over-the-counter medications, vitamins, or supplements you take. *

confirm that the information I provided is accurate to the best of my knowledge.

I understand that Direct Primary Care Associates may contact me by phone, text, or email regarding my care and onboarding.

Stay Connected

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Clinic Contact Information

If you are trying to contact our care team, please use the Spruce app or call your clinic.

Cleveland: 423-650-4831
Athens: 423-405-1990
Dalton: 706-229-8333
Loudon: 865-275-7255