New Patients – Dr. Heidi C. Mist

We ask that all prospective patients fill out the New Patient Intake Form. This can be filled out below and submitted once fully completed.

Patient Name*
First Middle Last
Date of Birth*
Home Phone
Cell Phone*
Email
Address*
Street Address Address Line 2 City State ZIP Code
Insurance Company*
ID#*
Secondary Insurance Company
ID#
Last Primary Care Physician*
Why did you leave your last physician/any specific problems?*
How did you hear about our office?*
Please fill out the following questions as accurately and as fully as possible. Omissions will be treated as a reason for dismissal.
What medications are you currently taking? Please include vitamins, supplements, over-the-counter meds, and anything you take intermittently or on an as-needed basis.*
Any allergies to medications?
What is your preferred Pharmacy?
What medical problems have you been diagnosed with or informed of?*
What symptoms/complaints do you have now?*
Do you see any specialists?*
- Yes
- No
Which specialist?*
What surgeries have you had?*
Any recent hospitalizations/ER visits?*
- Yes
- No
Where?*
Why?*
Acknowledgement*
- This is a full disclosure of my current health information. I acknowledge that any conditions or medications not included will result in my acceptance into the practice being rescinded. I also agree that should any of this information change before my initial visit, I will notify the office immediately.
Please click the button below to submit your form after reviewing to ensure that your information is correct.