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Advanced Internal Medicine Group
Primary Care Internal Medicine  |  AIM Housecalls  |  Marijuana Medical
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New Patient Appointment Request
Patient Last Name *
Patient First Name *
Date of Birth *
Contact Number *
Cell Number
E-mail Address *
Primary Insurance *
If you do not have insurance please enter "Self Pay"
ID# *
If no insurance please enter "N/A"
Secondary Insurance
Referred By *
Office Use - Referral Info
Requested Doctor
Reason for Appointment *
For Medical Marijuana Only: What is your diagnosis which you are looking to utilize Medical Marijuana for?
For Harborside Only: Do you currently have a PCP?
Notes (For office use only)
Your Name and relation to patient
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