New Patient Registration Form

If you are a new patient at Baptist Medical Clinic | Family Medicine, please complete and submit the form on this page prior to your arrival. For the best possible patient experience, please submit your information at least two hours prior to your appointment.

Please note that you will need to provide your Social Security number and insurance card(s) to the receptionist when you arrive. All patient information must be completed in full. If you have insurance, we will be glad to help you file for any benefits to which you are entitled. However, it remains the responsibility of the individual patient to settle her/his account promptly. To help us file your insurance claim correctly, we must make a photocopy of your insurance card. All co-pay amounts must be paid at the time of the visit.

* = required field

New Patient Registration Form

New Patient Registration Form

Insurance Information

NOTE: You must provide the Insured's Social Security number to the receptionist when you check in at the clinic.

Preferred Pharmacy

Emergency Contact
In case of emergency, who should be notified?

Baptist Flame

Baptist Health Systems


Find A Doctor



Baptist Medical Clinic

Patients & Visitors


Contact Us

Physician Tools

Careers at Baptist

Employee Links

Online Services

At Baptist Health Systems

At Baptist Medical Center

close ×