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 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 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 *

TERMS & AGREEMENT *

By enrolling in this payment plan, I, the responsible party authorize auto-withdrawals and commit to making timely payments. By submitting this form, I authorize Progressive Medical Associates to charge my credit card monthly in the amount indicated above until my balance is paid in full. As the responsible party, I understand that if I default, I will have 30 days to settle the balance, after which my account will be sent to collections. I also agree to notify Progressive Medical Associates immediately if my card information changes by calling (704)766-0320, Option 6.

Signature *

Type Name of Cardholder

* Required field