Progressive Medical Associates PLLC

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 FORM FORGOT MY USERNAME MAKE A CO-PAYMENT ON YOUR ACCOUNT MAKE A PAYMENT ON YOUR ACCOUNT MAKE PAYMENT ARRANGEMENTS UPDATE DEMOGRAPHICS UPDATE EMAIL ADDRESS UPDATE INSURANCE INFORMATION VITALS & CO-PAY

MAKE PAYMENT ARRANGEMENTS

First Name *

Last Name *

Address *

Date of Birth *

Amount of Monthly Payment *

Please enter the dollar amount that you agree to pay per month. Your credit card will be charged the amount you have indicated monthly until your balance is paid in full.

Credit Card *

Visa

MasterCard

American Express

Discover

Cardholder's First Name *

Cardholder's Last Name *

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 Assoc to charge my credit card monthly in the amount indicated above until my balance is paid in full.

Signature *

Type Name of Cardholder

* Required field