New Patient Appointment Request

If this is an emergency, please call 911 or get to the nearest emergency room.

How did you hear about Dr. Alan F. Bain, DO?

Patient First Name

Patient Last Name

Date of Birth

Email address

Home Phone

Cell Phone

Home Address

City / Village

State / Prov.

Zip

Country

Where should we send your prescriptions? PHARMACY NAME

Pharmacy Address

City

State

Zip

Emergency Contact Name

Emergency Contact Phone

Relation

How do you intend to pay for your visit?

Self Pay - Out of Pocket

$227 New Patient Visit

Bill Insurance

What is the reason for your visit?

Please explain the reason for your visit

Please list current medications you are taking, including vitamins:

Please upload any medical history, records, imaging or labs. You may also fax these to 877-325-2058

Add file

Please upload a file

Mark the areas on the image where you are experiencing symptoms

Your information will be encrypted.