new patient waitlist

As spots open we will be processing the requests by first come first serve.

Fill out the information below completely. If your preferred provider is still open to new patients, we confirmed that we accept your insurance, and that your insurance is active, we will reach out to you and pass along the New Patient Paperwork to complete.

Please note that we are a Membership Practice which includes a small yearly fee. For information regarding the membership visit the “SFH Membership” section of our site.

Name

First Name

Last Name

Date of birth

YYYY

Phone

(###)

###

####

Preferred Provider

Second Provider choice

Third Provider choice

Insurance Carrier

Insurance ID #

Additional Requests

Do you have a child or spouse you wish to join as well?

Yes

Additional Request Details

Please note their names and date of births. Please indicate if they have the same insurance as you, if different please include insurance details.

MEMBERSHIP

$180 per adult | $25 per child 0-25 years of age

I am aware that SFH is a Membership Practice that requires a small yearly fee upon scheduling my first appointment.

Paperwork Deliverable

If you are accepted, how would you like to receive the New Patient Paperwork?

new patient waitlist

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