About Us
Clinic
Physicians
Staff
Notice of Privacy Practices
Primary Care First & Medicare Shared Savings
Careers
Patient Portal
New Patient Inquiry
Patient Paperwork
Welcome to FPG
Demographics
Health History
Patient Health Questionnaire (PHQ-9)
Printable Forms
Medicare Wellness Form
Medical Minute
Satisfaction Survey
Family Physicians Group
About Us
Clinic
Physicians
Staff
Notice of Privacy Practices
Primary Care First & Medicare Shared Savings
Careers
Patient Portal
New Patient Inquiry
Patient Paperwork
Welcome to FPG
Demographics
Health History
Patient Health Questionnaire (PHQ-9)
Printable Forms
Medicare Wellness Form
Medical Minute
Satisfaction Survey
New Patient Inquiry
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Email Address
*
Phone
*
(###)
###
####
Were you referred to us? If not how did you hear about us?
*
If you were referred to us, who referred you?
Who is your insurance provider?
*
Please double check with your insurance company to make sure we are in network (We do not participate with CHI plans)
What would you like to be seen for? How soon would you like an appointment?
*
Do you have any immediate family? Will they be coming here as well? (Please list their names and ages.)
*
Do you have a preference on which of our providers you would like to see?
No Preference
Dr. Nancy Baugous
Dr. Peter Morin
Dr. Thomas Fischer
Thank you!
Thank you for your inquiry. A receptionist will call with your answer within 24 hours.