New patient packet · Online

Fill it out once, no printer needed.

About 15 minutes. Answer on any phone or computer, sign on screen, and we’ll turn it into a finished PDF you can print, save, or fax to us.

Private by design. Your answers stay on this device. Nothing is sent over the internet; the PDF is created right here in your browser.

Last name

First name

Middle initial

Date of birth

Gender

MaleFemale

Marital status

Previous name (if any)

Social Security number

Optional here. You can give it to us in person.

Employer

Race

WhiteAfrican AmericanHispanicOther

Cultural background (e.g. American, German, French)

Mailing address

Apt / suite

City, state, ZIP

Cell phone

Home phone

Work phone

Appointment reminders by

VoiceText

Voicemail number

HomeCellWork

Receive health information by email?

YesNo

Preferred pharmacy (name, location, phone)

Emergency contact

Full name

Relationship to you

Phone

Address, city, state, ZIP

Do you have health insurance?

YesNo, I’ll self-pay

No insurance? We are happy to see you at our self-pay rates, a 50% discount on standard charges. You’ll review the No Surprises Act notice at the end.

Reason for your visit

Your other healthcare providers, if any

Surgeries or hospitalizations, and when

Family medical history (chronic conditions)

Mother

Father

Siblings

Grandparents

Anything else we should know?

Medication allergies

Leave blank if none.

Current medications

Your current or previous family doctor

Screenings

Eye exam

Hearing test

Glaucoma screen

Cholesterol

Diabetes screening

Colorectal screening (colonoscopy, FOB, or sigmoidoscopy)

Mammogram

Pap smear

Clinical breast exam

Bone density

Prostate (PSA)

Abdominal aortic aneurysm screen

Vaccines

COVID-19 vaccine / booster

Influenza

Pneumonia

Tetanus

Shingles

Falls in the past year (number of falls or injuries)

May we speak with a family member, friend, or legal representative about your care?

Yes, I’ll name themNo, I decline

Should we request your records from a previous provider?

YesNo

Patient Financial Responsibility Statement

You are responsible for all charges, including deductibles, copays, and coinsurance, regardless of insurance coverage.
You authorize BHG to verify benefits, bill your insurance, and release information needed to process claims, and you assign insurance benefits to BHG.
Medicare patients: you request that authorized Medicare benefits be paid to BHG.
Balances are due within 30 days of your statement; accounts over 90 days past due may go to collections.
BHG may contact you by mail, phone, text, or email using the information you provide.

Read the full statement I have read and agree

Cancellation, no-show & late arrival policy

Please give at least 24 hours’ notice to cancel.
No-show or late cancellation fees: $25 the first time, $55 the second, and possible dismissal plus $75 after that. Fees are due before your next appointment.
Arriving more than 20 minutes late means your visit will be rescheduled.

I have read and agree

Notice of Privacy Practices

You acknowledge that you have been offered a copy of the practice’s Notice of Privacy Practices.

I have read and agree

No Surprises Act notice and consent (out-of-network or self-pay only)

Only check this if you are uninsured or BHG is out of network for your plan. You do not have to sign it, but if you don’t, BHG may not be able to see you.
By agreeing, you give up certain federal surprise-billing protections and agree to the self-pay estimate of $20 to $250 per service, at a 50% discount on standard charges.

See the fee estimate I have read and agree

Printed name of patient or representative

You are signing as

PatientGuardian / representative

Sign here

Use your finger, a stylus, or your mouse. Signing here is the same as signing the paper packet.

Fill it out once, no printer needed.

About you

Contact & emergency

Insurance

Health history

Medications & allergies

Screenings & vaccines

Mood & anxiety

Authorized contacts & records

Policies & signature

Review & create your PDF

Request an appointment