SouthEast Integrative Medicine

It's Your Life. Live It Well.

Home

About SEIM

General Information

Physicians of SEIM

Green Medicine at SEIM

Holistic Breast Care

Acupuncture

Information for Patients

New Patient Information

Current Patients

Diagnostic Testing

MEDICARE 2012

Recommended Resources

Environmental Medicine

More about Everything!

Employment

SEIM on Facebook

Mother Earth's Children

Natural Connection-Blog


New Patient Information Request

Patients who wish to establish with our practice are requested to complete the following information form. Please indicate the best way for us to contact you. We will e-mail you a New Patient Information Packet with instructions on how to return it to us.  Our doctors personally review all of your information so that we can decide how best to meet your needs. We will  contact you by the method most convenient for you to schedule your appointment. Please note that New Patient appointments typically last a minimum of one hour, and require a great deal of preparation on our part. The more we know about your concerns before your appointment, the better we can assist you!

You may also stop by our office in person to pick up a New Patient Information Packet.
We look forward to helping you with your health care needs!

Yours In Health, Dr. Pauline M Bellecci & Dr. Robert G Lee


First Name
Last Name
Address Line 1
City
State
Zip Code
Daytime Phone() -
Evening Phone() -
E-mail Address
Are you currently employed? Where?
A Brief statement of your goal for your first appointment
Physician Preference or First Available Appt?
Please indicate if you have a preference of days/times for your appointments
What is the best phone number to contact you?() -
Have you been seen by one of our physicians in the past? When?
Who is your current physician?
Year you were born?
Insurance Company (if any), or state NONE
If Medicare, is it a Medicare Advantage Plan?
How did you hear about us?

SouthEast Integrative Medicine
406 Riverside Dr., Waycross, GA 31501
912-287-1555
copyright Southeast Internal Medicine PC 2011