Request edit access
Anywhere Care - Patient Interest Form
Individuals seeking to establish medical services with Anywhere Care
Sign in to Google to save your progress. Learn more
First and Last Name *
Email
Mobile Number *
Which provider are you interested in visiting with?
Clear selection

Legal Disclaimers & Consent

• I understand that Anywhere Care is a self pay clinic and does not accept insurance at this time.

• I understand that submitting this form does not establish a provider-patient relationship. A formal in person evaluation or via a live video consultation is required before any treatment plans, diagnoses, or prescriptions can be issued.


 *
How did you hear about us at Anywhere Care? 

Where are you receiving treatment for your current conditions (clinic, provider, etc.)?
 *
Briefly describe what your needs are or type of care you are seeking?  (Description: e.g., primary care, hormone balancing, gut health, weight management, chronic fatigue, pain, alternative medicine, etc.)


(This is to ensure we have adequate resources to treat the individual)
 *
If you are taking controlled substance medications please list them below?

Required if you are currently prescribed controlled pain medications (oxycodone, morphine, percocet), stimulants for ADHD (e.g., Adderall, Ritalin), or benzodiazepines for anxiety (e.g., Xanax, Ativan).  

(Due to Utah regulations we closely monitor controlled substances and adhere to Utah guidelines at Anywhere Care)

What are your top 2 health or wellness goals for the next 6 months?

 *
Additional Information?
Once you submit the form someone will reach out to you either by telephone, text, or email.  Thank you from Anywhere Care.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Anywhere Care.

Does this form look suspicious? Report

Google Forms