Patient Forms

Name*
First Last
DOB*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone
Would you like to receive text messages?
- Yes
- No
Email*
Would you like Portal Access?*
Portal Access: Skypoint Medical Center is pleased to provide you with online access to your health information through our Patient Portal. Here you can view and create new appointments with our practice, exchange secure messages with our staff, update your contact information and insurance, read and print important forms, and access lab results and the latest data on Health . If you want to access an email will be sent to you.
Ethnicity*
- American Indian or Alaskan Native
- Asian
- Black or African American
- Native Hawaiian or Pacific Islander
- White
- Latino/Hispano
- Other
Marital Status*
- M
- S
- W
Languages*
Emergency Contact
Emergency Contact Name*
First Last
Emergency Contact Relationship*
Emergency Contact Phone*
How did you hear about the office?

To ensure that each patient is given the proper amount of time allotted to their visit and to provide the high quality of care that you deserve, it is very important that all scheduled patients arrive on time. Appointment cards are provided at the time of scheduling and reminder calls are made/attempted on the day before your scheduled appointment as a courtesy. If it is necessary to cancel your appointment, please call us as soon as possible. A minimum of 24hrs notice is required for cancelling appointments. If less than 24hr notice is given, the appointment will be considered 'Missed'. If you do not cancel in advance and do not attend the office for your visit, this will be considered a 'No Show' appointment. ***After the first No Show or Missed appointment, a $25.00 a fee will be charged at the Provider's discretion***
I have read the above policy and sign below to indicate that I have understood it's contents.*
- I agree

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