Request a House Call Form
This form is for new patients interested in our services

Please be mindful that once this form is submitted, additional information could be obtained by our medical assistant to fully register a new patient with our office.

An AFFIINITY HEALTH nurse or medical assistant will contact you by phone or email within 1-3 business days to complete the registration process (unless you are referred to us by a group home or health organization).

For assistance regarding a current AFFINITY HEALTH patient, please contact the patient’s our office.

Disclaimer: Because e-mail sent to and from this site may not be secure, you should take special care in deciding what information you send us via email.

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Who is submitting this request? *
Patient County or City- If the patient's City or County is not listed in the dropdown, we currently do not have services available.
 *
Patient First & Last Name *
Patient DOB *
MM
/
DD
/
YYYY
Patient Address *
Primary Contact Phone*
 *
Patient Preferred Pharmacy ( Name & Phone) *
Primary Insurance Name & Number *
Secondary Insurance Name & Number *
Primary Contact Email Address
 *
Where does the patient reside?
 *
How did you hear about us?
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