Your Information

Appointment Request

1. Your Info
2. Choose Provider
3. Your Appointment
4. Confirm

Step 1 - Your Information

This form is for appointment requests only. If you have a medical or pharmacy question, please contact your provider or pharmacy directly.

For assistance please give us a call at 1-877-722-6330 (Mon. – Thur. 7:00 am – 6:00 pm | Fri. 7:00 am – 5:00 pm | Sat. 8:00 am – 4:00 pm | Sun. 8:30 am – 1:00 pm).

All fields required unless marked optional.

Patient Information

Are you a new patient to Pacific Medical Centers?

No Yes

Appointment is for

Your name

First name

Middle initial (optional)

Last name

Date of birth

Next Next

New Patient Details

Gender

Female Male

Race

Please select your primary choice and as many secondary choices as necessary.

Secondary Race (optional)

American Indian/Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

Other

Unknown

Prefer not to state

Ethnicity

Address

Address 2 (optional)

City

State

Zip

Insurance Information

Medical insurance

I do not have (or do not care to provide) insurance information

Other insurance or payment type (optional)

Subscriber name

Subscriber date of birth

Subscriber's relation to patient

Subscriber number

Please include any letters in the subscriber ID

Group number

Claims mailing address (optional)

This address can usually be found on the back of your insurance card and will speed the registration process.

Current primary care provider or medical group (optional)

Contact Information

Email address

Confirm email

Best contact/message number

Primary phone type

Alternate contact/message number (optional)

Secondary phone type (optional)

Preferred contact method

May we leave a voicemail?

If your insurance has changed, someone may call you to obtain this information. If you do not receive a call, please present the updated information at check-in.

For assistance please call 1-877-722-6330 (Mon. – Thur. 7:00 am – 6:00 pm | Fri. 7:00 am – 5:00 pm | Sat. 8:00 am – 4:00 pm | Sun. 8:30 am – 1:00 pm).