NEW PATIENT CHECKLIST

• Driver’s License or Identification Card (Front and Back)

• Health Insurance Card (Front and Back)

• Social Security Card

• Power of Attorney (POA) Forms

• List of Current Medications and Dosages

• Living Will and DNR Forms (if applicable)

• Any Medical Records

FORMS

NEW PATIENT PAPERWORK (PDF)

CONSENT FORM (PDF)

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Please send the completed document to our email or fax number:

Fax: (480) 436-6926

Email: info@agapeprimary.com