New Patient Request Form-Family Medicine

New Patient Request Form

Let us know how we can help you!
Welcome to Northwest Family Medicine

Thank you for choosing us for your primary care needs. To better serve you, we have locations in Athol, Coeur d'Alene, Post Falls and St. Maries. Please complete the contact information below and someone from our team will be reaching out to you.
Full Name*

Last NameFirst Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
CellHomeWork
Guarantor *
Patient Relationship To Guarantor *
Insurance Coverage (example: Blue Cross, Aetna, Cigna, Pacific Source)*
Subscriber/Member ID (be sure to include the 3 digit alpha prefix if noted on card)*
Policy Holder Name *
Policy Holder Date Of Birth *
AtholCoeur d'AlenePost FallsSt. Maries
Holly Collins, FNP-CKristin Comstock, MDRachel Kallemeyn, NPThomas Neal, MD (not currently accepting new patients)Connie Wilson, FNPNo preference - first available provider
Brittney Bowen, FNP-CStephanie Gallaher, FNP-CScott Gibbs, PA-C (not currently accepting new patients)Heidi Herold, MDKatie Jarstad, PA-CHeather Sarkis, PA-CNo preference - first available provider
Vanessa Graves, MDMegan Linders, DOJared Mudge, PA-CDean Sparks, PA-CNo preference - first available provider
Clyde Hanson, DORebekah Myers, NPRalph Sutherlin, DONo preference - first available provider
Please note, Northwest Specialty Service Line Clinics considers a patient a "No-Show" if they miss an appointment, or do not notify the clinic a minimum of 24 hours prior to canceling an appointment enabling us adequate time to offer the canceled slot to another patient. If less than 24 hour cancellation is given, the appointment becomes a "Missed" appointment. There will be a $50.00 fee charged for a second no-show or late cancellation of an office visit. If you incur a 3rd "No-Show/Missed" appointment within a one year time period, you may receive a letter from our office notifying you that you have been discharged from our office and must find a new care provider.
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New Patient Request Form

Welcome to Northwest Family Medicine