New Patient Intake

Thank you for your interest in becoming a patient of Healthworks Family Medicine!

The first step towards becoming a patient is the completion of this new patient intake form. This content submitted on this form is used to screen patients to ensure that we are in-network with your insurance plan as well as to conduct a medical screening to ensure we are a good fit for your medical management needs.

A member of the Healthworks Family Medicine Team will contact you soon after the completion of this form to schedule your first appointment. If we are unable to serve you, we will let you know that as well.

Healthworks Family Medicine | Paducah, KY | Primary Care | Pediatric Care | Sports Medicine

Patient Intake Form

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

Current Physician's Name

Current Physician's Address

Are you under the care of any specialists (e.g. Cardiologist, Neurologist, Urologist, Etc)?(Required)

Yes

No

Specialist Name

Specialist Address

Specialist #2 Name

Specialist #2 Address

Insurance Information

Our office is not in-network with all insurance providers. Please upload a copy of your insurance card so that we can check to see if we are an in-network provider for you.

Please Upload Front of Insurance Card(Required)

Max. file size: 3 MB.

Please Upload Back of Insurance Card(Required)

Max. file size: 3 MB.

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