new patients

COMPLETE FORMS BELOW

NEW PATIENT FORMS

These 7 forms must be submitted before you schedule an appointment.

1. INTAKE FORM

2. PATIENT POLICY AGREEMENT

5. CONSENT FORM

6. CAGE FORM

3. INSURANCE CARD UPLOAD

7. ADULT HISTORY FORM

4. CREDIT CARD AUTHORIZATION FORM

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Request an appointment below and we'll get you set up with your Patient Portal.

You will need to upload your insurance and credit card information (for co-pays) and fill out the necessary forms for insurance billing. Then you can access our convenient self-scheduling feature. Please allow the billing department up to five business days to ensure that all paperwork is thoroughly processed before scheduling your new visit.

PLEASE NOTE: Your appointment will not be valid until all forms, insurance, and credit card for co-pays are processed. If these steps are not completed by the day of your appointment then your appointment will be canceled.

QUESTIONS? Call our billing office at 612-886-6112, or the Miles Med Management number, 612-708-7562.

Request Appointment

Phone: 612-886-6112

Mobile: 612-237-9238

Fax: 949-258-0567