New Patients | My Site

top of page

NEWSLETTER

ABOUT

To become a new patient please fill out this form.
Hit the SEND button.
We will contact you to set up an appointment

First name

Date of Birth: MM/DD/YYYY

Last name

Sex

Male

Female

Street Address

Street Address Line 2

City

State

Zip code

Primary Phone

Alternate Phone

Your Email

I give permission for Advanced Medical Care to send text messages to my Primary Phone.

YES

I give Advanced Medical Care permission to leave content messages by: (check all that apply)

Text to my Primary Phone

Voicemail to my Primary Phone

Insurance Company Name

Patient Insurance ID Number

Social Security Number

I am anxious to help you with some of your specific medical issues, but our office is only open part time and we are not available to deal with the many routine, unscheduled medical needs that arise. Therefore it is important for all of our patients to also have a Primary Care Provider in addition to Advanced Medical Care. Please type your name below to indicate you understand.

Reason for Coming In

Anything Special We Need To Know About You or Your Medical Condition

I take prescription medication for the following conditions: (check all that apply)

Heart disease

High blood pressure

Asthma or COPD

Arthritis/fibromyalgia

Insomnia

Depression or anxiety

Headaches or migraines

Diabetes-I do NOT take insulin

Diabetes-I DO take insulin

We will contact you to schedule your appointment.

There are 3 things you should bring to your first appointment.

1. Your Drivers License

2. Your insurance card, including secondary insurance if applicable.

3. All current medication, prescription and OTC. Bring a written list or the actual bottles.

If you have any questions call 360-264-2492, or use the Contact Form below.

Advanced Medical Care

1006 Kresky Ave, Ste 1

Centralia, WA 98531

Office Hours Vary.

For an appointment, call: 360-264-2492

Medical Fax: 833-694-1504

For Any Questions Contact Us Here

First Name

Last Name

Add message or question here. Include your phone number if you want a call back.

Thanks for submitting!

bottom of page

To become a new patient please fill out this form. Hit the SEND button. We will contact you to set up an appointment

For Any Questions Contact Us Here

To become a new patient please fill out this form.
Hit the SEND button.
We will contact you to set up an appointment