Progressive Medical Associates PLLC - Publicforms

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Available Forms

**NEW PATIENT (1) - REGISTRATION FORM **NEW PATIENT (2) - HEALTH QUESTIONNAIRE **NEW PATIENT (3) - HEALTH SCREENINGS **NEW PATIENT - MEDICARE (Age 65 + ) *ANNUAL WELLNESS (Age 65 + ) *ANNUAL WELLNESS (Under Age 65) CONTACT REQUEST FORM FORGOT MY USERNAME MAKE A CO-PAYMENT ON MY ACCOUNT MAKE A PAYMENT ON MY ACCOUNT MAKE PAYMENT ARRANGEMENTS UPDATE MY DEMOGRAPHICS UPDATE MY EMAIL ADDRESS UPDATE MY INSURANCE INFORMATION VITALS & CO-PAY

MAKE A PAYMENT ON MY ACCOUNT

Apply payment to the following patient account:

First Name *

Last Name *

Amount of Payment *

CREDIT CARD INFORMATION

Cardholder's First Name *

Cardholder's Last Name *

Credit Cards Accepted *

Visa

MasterCard

American Express

Discover

Card Number (No Spaces) *

Expiration Date (MM/YY) *

CVV Code *

Billing Address with City and State *

Billing Zip Code *

By submitting this form, I authorize Progressive Medical Associates to charge my credit card for the amount indicated above.

Signature *

Type Name of Cardholder

* Required field