Tricity Family Medicine & Urgent Care

Available Forms

0.1: Appointment Request 1: PATIENT DEMOGRAPHIC FORM 2. HIPAA FORM 3: FEES, PAYMENT & BILLING POLICIES 4: CREDIT CARD ON FILE POLICY 5: OFFICE POLICIES 6: LAB BILLING POLICY 7. Lab Result Follow-up question 8. Prescription Refill Request 9. Referral Request/ Question A1. Billing Question Address/Contact Information Update Form Adult Annual Wellness/ Physical Exam Pre-visit Form Blood Pressure Log Blood Sugar Readings Cancer Screening Services Record Update GAD-7 Generalized Anxiety Disorder Healthcare Questions Insurance Update Form Password Request The Mood Disorder Questionnaire (mdq) Z: Patient Satisfaction Survey - Care at Tricity Family Medicine Z: Patient Satisfaction Survey - Community Referral Process Z: Patient Satisfaction Survey - Referral Process (Coordination of Care) Z: Specialist/Hospital Care Coordination Form

0.1: Appointment Request

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Gender *

Male

Female

Declined

Street Address *

City *

State *

Zipcode *

Preferred Contact Method *

Home Phone

Work Phone

Cell Phone/ Text Message

Portal

Preferred Contact Number *

Email *

New Patient *

Yes

Preferred Office Location *

Holly Springs Office

West Cary Office

Provider preference *

Chaitany Patel, MD

Kristen Geyer, FNP

Rebecca Knopf, FNP

Alexa Moore, FNP

Sarah Mitchell, FNP (Starting Jan 02, 25)

No Preference

Preferred Appointment Date *

Preferred Appointment Time

8:00 am to 10:00 am

10:00 am to 12:00 pm

2:00 pm to 4:00 pm

4:00 pm to 5:00 pm

Please give us 24 hours to schedule your appointment. If you need to be seen sooner, feel free to call our offices directly Holly Springs 919-363-8666 or Cary office 919-261-6446. <br/>SICK WALK-INS WELCOME. Please stay in your car and inform us of your arrival.

Type of Insurance - Please select *

Please select

Policy Holder/ Subscriber's Full Name *

Policy Holder/ Subscriber's Date of Birth *

Patient's relationship to Subscriber *

Self

Child

Spouse

Other

Patient's Member ID *

Please note if you insurance has 2 digits next to patient's name. Add those 2 digits to the end of your member ID.

Insurance Provider phone number *

Please provide the Provider Service Phone number on the back of your card.

Reason for Visit *

During COVID- All sick visits please wait in the car and inform us of your arrival.

Do you have Secondary Insurance *

Yes

Please be sure to bring all IDs to your visit.

Secondary Insurance Details

Please provide the Insurance Plan Name, Member ID, Subscriber Name & Date of Birth

How did you hear about us? *

Sick Walk-ins Welcome.

Our appointment coordinator will contact you via the method you select to confirm your appointment. If you do not hear back from us in 24 hours then Call our Holly Springs office at 919-363-8666 or Cary office 919-261-6446 for further assistance. We kindly ask that if you must change an appointment, please give us at least 24 hours notice.

APPOINTMENT/ CANCELATION/ NO SHOW POLICY

Excessive No Shows & Late Cancellations -Patients who have 3 or more missed appointments within any given 12-month period or who have an excessive history of late cancellations, missed appointments, or a combination of the two will be subject to maintaining a credit card on file for $50 deposit to book future appointments or non compliance of the policy may result in patient dismissal from the practice. Please be advised that missed appointment fees will be assessed to your account and charged to your credit card on file within 7 days of the appointment. We do not generate statements for missed appointment fees. NOTE: Immigration Physical requires $50 non-refundable deposit that applies towards the visit.

* Required field