Carolina Internal Medicine has limited capacity to see new patients at this time.  A waiting list for new patients is being maintained.  In order to be placed on this waiting list please fill out the information below and we will call to schedule the new patient appointment as one becomes available.  We are sorry for any inconvenience and trust we can schedule an appointment for you within a reasonable amount of time.  We are not participating providers for United Health Care.  Fax form to:  828-258-3390 or mail to this office.

Date:_______________________                                 

Full Name: ___________________________________   Date of Birth ____________

Phone #: (H) ________________   (W)_________________  (Cell)______________

Address ____________________________________________________________

             _____________________________________________________________

Social Security Number: __________________   Email Address:_________________

Previous Physician: ____________________________________________________

Problem (s): _________________________________________________________

                   _________________________________________________________

Current Medications:___________________________________________________

                                ___________________________________________________

Do you take any Narcotic Medications?   yes   or   no

Referred By: _________________________________________________________

Employer: ___________________________________________________________

Insurance:____________________________________________________________