Progressive Medical Associates PLLC

Available Forms

** New Patient - Medicare & Medicare 65+ ** New Patient - Non-Medicare & Under 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

VITALS & CO-PAY

Please take 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). If you owe a copay for your visit, please provide your payment information, below. Thank you! Progressive Medical Associates

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