New Patient Inquiry Form
This form is not intended for urgent needs. Please allow up to 24 hours for a response. If you have a medical emergency, call 911 or go to your nearest emergency room.
Reason for visit
*
Please Select
Expecting Parent
Well-child visit
Sick visit
Newborn enrollment (Must be born and scheduled within 24-48 hours of discharge)
Child’s Full Name
*
Does the child have siblings at this practice?
Please Select
Yes
No
If yes, please list their name(s) and date of birth:
Patient Sex
Please Select
Male
Female
Are there any additional siblings who need to be established as patients with our practice?
Please Select
Yes
No
If yes, please list their name(s) and date of birth:
Date of Birth
-
Month
-
Day
Year
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the Parent/Guardians address the same as the patient?
Please Select
Yes
No
Parent/Guardian 1 Information
Full Name
*
Phone Number
*
Format: (000) 000-0000.
Phone type
Please Select
Home
Cell
Work
Email Address
example@example.com
Parent/Guardian
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 2 Information
Full Name
Phone Number
Format: (000) 000-0000.
Phone type
Please Select
Home
Cell
Work
Email Address
example@example.com
Parent/Guardian
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which of our locations do you prefer to seek care for your child?
*
Please Select
Cary
West Cary
Raleigh
Wake forest
Rolesville
Clayton
Holly Springs
Brief message
Best time to call
Do you currently have insurance?
Please Select
Yes
No
Insurance Accepted
Please Select
Aetna
Blue Cross / Blue Shield (we are contracted with "BCBS Blue-Value Plan")
CIGNA / Healthsource / Connect
Contigo Health (WakeMed Employees)
First Health
Great West
MedCost
PHCS/Multiplan
Medicaid - Wellcare/Healthy Blue/United Healthcare
Primary Physician Care
State Health Clear Pricing
United Healthcare
UMR(United Medical Resources)/Golden Rule
Wellpath / Coventry
Tricare Standard/East
Medi-Share
Liberty Health Share
Other
Insurance Type
How did you hear about JMA Pediatrics?
Please Select
Facebook
Instagram
Website
Google
Friend/Family
Business
OBGYN
Other
Other (please specify)
I understand this is a request for contact and not a medical emergency.
*
Yes
No
Submit Request
Should be Empty: