Practice Locations

Hickory Office
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1771 Tate Blvd. SE
Suite 201
Hickory, NC 28602
Phone: (828)324-4804

Morganton Office
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2209 South Sterling St
Suite 600
Morganton, NC 28655
Phone: (828)430-7655

Lenoir Office
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1041 Morganton Blvd.
Suite 101
Lenoir, NC 28645
Phone: (828)754-3988

New Patient Form

We encourage you to fill out a new patient form before coming to the office. This will save you time and make the office administration process easier.

Patient Information

First Name:		Middle:		Last Name:
Email Address:

Date of Birth:		Gender:		Social Security Number:
		MaleFemale

Address:	Suite/Apt/No.:	City:	State:	Zip:

Home Phone:		Cell Phone:
Employer:		Work Phone:
Primary Care Physician:		Phone:
Pharmacy:		Phone:

Insurance Information

First Name:		Middle:		Last Name:
Email Address:

Address:	Suite/Apt/No.:	City:	State:	Zip:

Date of Birth:		Gender:		Social Security Number:
		MaleFemale

Primary Insurance Company:
Policy Number:			Group Number:
Secondary Insurance:
Policy Number:			Group Number:

Spouse's Information

First Name:		Middle:		Last Name:
Email Address:

Date of Birth:		Social Security Number: