Inquiry

Staff member filling out form:*

(Your Name)

Contact's First Name

(Name of the person calling)

Contact's Last Name

Patient's First Name (If different)

Patient's Last Name (If different)

Phone

(A phone number or email is required)

Email

Medicat ID number (if you created one)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are they asking about a specific provider?

Dr. Ron Hunninghake
Dr. Dustin Moffitt
Dr. Lucas Tims
Mike Shaw, PA-C
TBD (no specific request)

What would they like information about?

Cancer & oncology
Lyme Disease
Hormones
Weight Loss
Prolozone or PRP (regen. medicine)
Fatigue
Other/Unknown (add notes in comment box)

Would they like to receive our Health Hunters Newsletter each month?

Yes!
No thank you
They already do

Did you schedule them for a new appointment?

Yes
No

If you added an appointment, or blocked time for a specific appointment, mark "yes" and then add the Medicat ID number below. If no ID number, add the date/time of the appointment in the comments box below. Thank you!

Did you send the new patient paperwork?

Yes, I sent it by EMAIL
Yes, I sent it by MAIL
No, I haven't sent it. Please send!

Comments

Misc. notes or information:

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Internal Form: New Patient Inquiry