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




Are you currently on any prescription medications?
...NoYes




Do you need refills for any prescription medications?
...NoYes




Have you had any surgeries or any major procedure done in the past?
...NoYes




Do currently or previously smoke tobacco, drink alcohol or used any illicit drug?
...NoYes




Any family history of cancer, Heart disease, diabetes, genetic disorders?
...NoYes




Do you have any acute health concerns today?
...NoYes




I agree with ApexMDClinic Primary and Urgent Care PLLC's Primary Care Patient Policy