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

VITALS & CO-PAY

Please get your weight, temperature, and blood pressure prior to your scheduled phone appointment. Enter the results below or indicate that you were unable to (for example, if you do not have a blood pressure cuff). Thank you!

NAME *

Date of Phone Appointment *

Patient Sex Assigned At Birth *

Gender

How do you choose to identify and what are your choice pronouns, if any?

Blood Pressure *

Weight *

Temperature *

Please submit your credit card information for your co-pay, which will be charged on the day of your appointment. If you do not have a co-pay, scroll to the end of this form and click "SUBMIT FORM"

Amount of Payment

Credit Card Type

Visa

MasterCard

American Express

Discover

Card Number (No Spaces)

Expiration Date (MM/YY)

CVV Code

Billing Street Address

Billing Zip Code

Type your name below to authorize Progressive Medical Associates to charge the credit card above for your co-pay. Thank you!

Electronic Signature

* Required field