New Patient Information Online Form

Fill in blanks below, then click SEND EMAIL (if you don’t send it we won’t get it!).
We also have a printable form if you wish to fax instead. If you want to sign up for the Community Supported Healthcare Plan, please also fill out the CSH Form when you are finished. We are also accepting donations for our Medicine Support Fund for seriously ill patients if you care to participate.

* Patient Name

Parent/Contact Person

* Email

* Phone

Alternate Phone

* Mailing Address street, city, state, zip

UPS Address if the above address is a PO box, please give a physical address here

* Age

* Date Of Birth

* Height

* Weight

* In one sentence, please describe what brings you to consult with Dr. Cowan

* How would you like to pay for your appointment? Community Supported Healthcare Plan
Pay out of pocket
Medicare

Please fill out the following if you have Medicare. PLEASE NOTE: We can only take it as a primary and if you have not signed up with any kind of plan like an HMO.

Medicare Number & Letter

Secondary Insurance (Medicare Patients Only)

Group #

Phone #

Address

Due to the number of missed appointments, we now have a 24-hour cancellation policy.

Billing Agreement I give my permission to run my card for any missed appointments without 24 hours notice and for bills due after 60 days if no prior pay agreements have been made. *

* Verify

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Dr. Thomas Cowan: Holistic Family Medicine

Working With the Fourfold Laws of Nutrition, Therapeutics, Movement and Meditation in the Art of Medicine

New Patient Information Online Form