OLD Clinic- New Patient Information

New Patient Information

Please fill in the form below if you've never been seen at our clinic
Are you sick or hurt today?*

YesNo
Please call 901-272-0003, Mon-Fri from 7am-4:30pm for a same day or next day appointment, or dial 911 if you are having an emergency.
We are experiencing a longer than normal wait time to become an established patient. We are accepting new patients on a very limited basis.

If you are on the MEMPHIS Plan, have been assigned to Church Health by your insurance or are interested in our family medicine clinic, please call 901-272-0003.

Please see this list of available clinics in Shelby County that are accepting new patients with no wait time.

Memphis Area Clinics for the Uninsured
Patient Full Name*

PrefixFirst NameMiddle NameLast Name
Is the patient under 18 years old?*

YesNo
Parent/Legal Guardian Full Name*

First NameLast Name
Patient Social Security Number
Patient Birth Date*

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Address*

Street Address

Apartment Number

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Postal / Zip Code
Phone Number*

Area CodePhone Number
Alt Phone Number

Area CodePhone Number
E-mail
Preferred Language*
Language
Marital Status*
Do you have health insurance?*

Yes (please indicate the kind below)No
Insurance

MEMPHIS PlanMedicareBluecareWellpoint (formerly Amerigroup)CoverKidsHumanaUnited HealthcareOther
Race*
Ethnicity*
How did you hear about us?*

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