Form

New Patient Request Form

Email*

Have you ever been seen at a Catawba Valley Family Medicine practice in the past?*

Yes

If yes, which doctor did you see?

Would you prefer an appointment with a specific CVFM provider or first available?*

Currently accepting new patients: Dr. Rebecca Hatharasinghe; Kristin Gottry, NP; Michael Faulkner, DNP, FNP-C

First Name*

Last Name*

Gender

Male

Female

Prefer not to share

Date of birth*

Previous Name (if any)

Street Address*

City*

State*

Zip Code*

Home Phone #*

🇺🇸

Cell #*

🇺🇸

Work #*

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Insurance Coverage*

Who was your last Primary Care Physician?*

Reason for leaving your last Primary Care Physician?*

Please list all current medications*

Please list all previous surgeries and on-going medical conditions: (hypertension, diabetes, etc.)*

How did you hear about us ?*