APPLICATION for New Patients: Accepting All Patients
Please print and fill out. Return form to: 123 Weaver Road, Ste A, Blairsville, GA 30512 or fax to 706-439-6482. If you are unable to print this form, please stop by our office to pick up an application. All information is held strictly confidential. Your information will be reviewed and considered, and you will be contacted shortly after submission of this form. This information will also be used to set up your chart when you are scheduled for your appointment. If you are not contacted within 3-4 business days, please call our office.
Date of Birth: Male or Female
Insurance: Phone/Contact Number:
For your first new patient appointment, would you prefer:
___Blairsville Office: Joe Livingston, MD; Thomas Gary, MD;
David Zollinger, PA; Callie Gordan, FNP, Katie Storms, FNP
___Hiawassee Office: Jonathan Lawrence, MD
___Blue Ridge Office: Thomas Gary, MD; Crystal Gary, MD
Tiffany Boring, FNP
___ earliest available appointment in ____________________________.
Please list ALL medications/supplements that you take including dosage and frequency taken. If a specialist or other physician will be prescribing some of these medicines, please make note of this next to the medicine. Medication prescribing is at the professional discrepancy of the provider. There are a variety of controlled substance medications that we do NOT prescribe.