APPLICATION for New 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. Once accepted, 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.

Name:

Date of Birth:                                              Male    or     Female


Home Address:                                              

 
Insurance:                                                  Phone/Contact Number:


For your first new patient appointment, would you prefer:

     ___Blairsville Office:     Joe Livingston, 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 Blairsville


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.