New Patient Registration
Prior to completing this form, it is imperative that you acknowledge and consent to the following terms:

  • You agree to electronically submit this form, wherein typing your name and clicking the final "SUBMIT" button serves as your electronic signature.
  • You are willing to provide your email address and accept a copy of your responses sent to that email address. This step is necessary to ensure the proper association of your responses with a valid individual and their respective contact information.
  • You acknowledge that you are utilizing this form as a means to become a new patient and initiate treatment within our facility.
  • Before proceeding, it is essential to verify that your insurance designates Larry Vigilia as your primary care provider.
This online form completion process is designed to streamline your first visit as a new patient, ensuring that you can attend your initial appointment with ease and without the need to complete paperwork on-site.
Should you disagree with these terms, please do not continue completing the form. You can access a printable version of these documents at junixmedical.com.
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Email Address *
First Name/Nombre 
 *
Last Name/Apellido  *
Birth Date/Fecha de Nacimiento
 *
MM
/
DD
/
YYYY
Age/Edad
 *
Address/Dirección *
City, State, Zip Code/
Ciudad, Estado, Código Postal
*
Cell Phone/Número Celular
 *
Is it okay for us to contact your cell phone?/
¿Podemos comunicarnos para la cita?
 *
Home Phone Number/Número de teléfono de casa
 *
Work Phone Number/Número de teléfono del trabajo
Sex/Sexo
 *
Marital Status
 *
Emergency Contact/Contacto de Emergencia *
Emergency Contact's Phone Number/Número de teléfono del contacto de emergencia *
Social Security Number/Número de seguridad social
 *
Driver's License Number/Número de carnet de conducir 
 *
Primary Language/Lenguaje primario
 *
Do you need an interpreter?/¿Necesitas una intérprete?
 *
How Were You Referred to Our Office/¿Cómo fue remitido a nuestra oficina? 
Clear selection
Preferred Pharmacy/Farmacia Preferida *
Pharmacy Address/Dirección de la Farmacia *
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