NEW PATIENTS

START HERE

If you are a new patient and would like to be seen by Dr. Hughes, please take a moment to fill out our new patient form before scheduling an appointment. Once completed, you can make an appointment by the "make an appointment" button.

A PDF version of the form is also available below for patients who need/prefer a printable version. You can submit the physical form when you arrive for your appointment.

PATIENT INFORMATION

MEDICAL HISTORY

PRIVACY ACKNOWLEDGEMENT

INSURANCE CLAIM

MAKE AN APPOINTMENT

Step 1 of 4

Patient Info
First Name*
Last Name*
Birth Date*
MM slash DD slash YYYY
SSN*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*

NEW PATIENTS

START HERE

Step 1 of 4

Patient Info

Employment Info

Insurance Info

Signature and Payment Policy