SouthEast Integrative Medicine

It's Your Life. Live It Well.

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New Patient Information

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 New Patient Information Packet with instructions on how to return it to us. After we have reviewed your information, we will  contact you by the method most convenient for you to schedule your appointment.

You may also stop by our office in person to pick up the Patient Information Packet--We look forward to helping you with your healthcare needs!


First Name
Middle 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
Have you been seen by one of our physicians in the past?
Who is your current physician?
Please indicate if you have a preference of days/times for your appointments
What is the best phone number to contact you?() -

SouthEast Integrative Medicine
406 Riverside Dr., Waycross, GA 31501
912-287-1555
copyright Southeast Internal Medicine PC 2010