Request to be our primary care patient

Health Insurance *


Are you currently up-to-date on all the vaccines?
...Yes - Please bring your vaccination records at the time of your first visit.NoNot Sure

Do you have any past medical history of any chronic disease?
...NoYes
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Are you currently on any prescription medications?
...NoYes
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Do you need refills for any prescription medications?
...NoYes
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Have you had any surgeries or any major procedure done in the past?
...NoYes
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Do currently or previously smoke tobacco, drink alcohol or used any illicit drug?
...NoYes
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Any family history of cancer, Heart disease, diabetes, genetic disorders?
...NoYes
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Do you have any acute health concerns today?
...NoYes
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I agree with ApexMDClinic Primary and Urgent Care PLLC's Primary Care Patient Policy