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New Patient Inquiry

Learn more about becoming a new patient by filling out our secure online inquiry form. After we receive your completed form, a Patient Services Representative will contact you by phone to discuss appointment availability and registration options. We look forward to speaking with you.

We value your privacy and want you to be informed of how we may use and disclose your protected health information. For specifics, please read our Notice of Privacy Practices. Data submitted through this form will be transmitted securely and in compliance with applicable laws and regulations.

Martin’s Point Health Care accepts most major health insurance plans, including most HMOs and PPOs. If you do not see your health plan on our list, please contact your plan directly to ask if Martin’s Point providers are in your health plan’s network.

Please select desired Health Care Center location.

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Health Care Center*

Your Contact Information

First name* Last name* Date of Birth Legal Gender*

Address* City* State* Zip Code* Email* Preferred contact phone number*

Additional Information

Race Ethnicity Marital Status How did you hear about us? Consent to call?*

Insurance Company Information

Insurance Company* ID Number* Group Number* Patient's Relationship to Payment Guarantor*