New Patient Registration at Evergreen Family Clinic | Evergreen family clinic pllc

Now Open!
Walk-ins welcome • Same-day appointments • New patients accepted!

Home
Services
About
Contact
Patients Registration
Appointment

Home
Services
About
Contact
Patients Registration
Appointment

VISIT US

Name*

Date of Birth m/d/yr*

Email*

Phone number*

Gender*

Male

Female

other

Payment method*

Card Payment

Insurance

Relationship to the Patient (e.g., self, spouse, parent)

Current Medications (including dosage and frequency if any)

Known Allergies (medications, food, or environmental allergies)

Chronic Conditions/Medical Issues (e.g., diabetes, hypertension, asthma)

Family Medical History (particularly hereditary conditions like heart disease, cancer, etc.)

Primary Concern/Reason for Visit*

General check-up

Follow-up

Illness

Injury

Other

Symptoms/Specific Issues

General Health: eg ;- Fatigue

Skin: eg ;- Rash, Itching

Head & Neck: eg; Headaches, Migraines

Respiratory: eg;- Cough, Shortness of breath

Cardiovascular: eg;- Palpitations or irregular heartbeat

Gastrointestinal: eg;- Abdominal pain or discomfort

Urinary: eg;- Painful urination, Frequent urination

Musculoskeletal: eg;- Joint pain or swelling, Muscle aches or weakness

Neurological: eg;- Numbness or tingling, Weakness in arms or legs

Endocrine: eg;- Excessive thirst or urination, Heat or cold intolerance

Mental & Emotional Health: eg;- Anxiety, Depression, Panic attacks

Reproductive Health (Women): eg;- Irregular periods, Painful periods

Reproductive Health (Men): eg;- Pain or swelling in testicles, Erectile dysfunction

Other

New Patient Intake Form

Welcome to Evergreen Family Clinic! We're excited to help you on your health journey. Please take a few minutes to complete the following form to ensure we have all the information needed to provide you with the best care possible.

Note: All information you provide will be kept confidential and secure.

If you have any questions or need assistance while filling out the form, feel free to contact us at 206-420-5325.

Before You Begin:

Make sure your information is accurate and up-to-date for efficient care.
Complete all fields marked with a * (asterisk) as they are required for your appointment.
If you’re a new patient, make sure to include insurance details (if applicable) to expedite the process.

Patient Information

Contact

Get in touch for your healthcare needs today.

Hours

Services

info@evergreenfamilyclinic.com

206-420-5325

Enter your email address

© 2025. Evergreen Family Clinic Pllc. All rights reserved.

Terms and Conditions

Developed by irunguwebdevelopers.com