Adult New Patient Application

If you'd like to join our practice, please fill out this form. Once this is completed and approved, we will then send you a link to our patient portal to enter your demographic and insurance information. You can ask questions, request prescription refills, download your results, and even schedule your own appointments. This service is offered for free for all existing and new patients.

We are currently only accepting 1 new patient per provider per day, due to a high census. We are only accepting new patients from the insurances in the drop down below. If your insurance is not on the drop down, we are not taking new patients from your insurance company.



Your Name *
Your Name
Please let us know if you're coming to us for Medical Care, Behavioral Counseling, or all primary care services.
Payment and No-Show Policy *
Atembis LLC requires payment of copay at time of visit, outstanding balances are due immediately, and no show fee for failure to show or cancel within 24 hours of a visit ($80 for medical, $120 for behavioral visits). By checking below, I understand and agree to this policy.
Address *
Date of Birth *
Date of Birth
Date of Birth
Cell Phone (or home # if no cell phone) *
Cell Phone (or home # if no cell phone)
Other Phone
Other Phone
Please choose your insurance (or cash) plan. We do NOT accept any AHCCCS plans. If you are unsure if we accept your insurance, please contact your insurance carrier first. If your insurance is not on this list, it is likely that we do not accept it. We do not accept third party billing or payment agreements.
Please enter your Insurance ID# here. This will help us determine if we accept your insurance plan. If you are self-pay, please leave this blank.
Please enter your Group Number here. This helps us determine if your group is within our contracted networks. If there is no group number or you are self-pay, please leave this blank.
If you have an EAP program and number, please enter it below.
Click on all medical problems you have or have had: *
Any cancer history? *
Have you had any surgery? *
This is generally to ask if you've ever had a procedure which required general anesthesia
Medication Agreement *
We here at Atembis LLC are actively involved in reducing the epidemic of prescription drug abuse in our community. It is for this reason that it is important that all new patients understand that 1) we do NOT write any regular prescriptions of opiates for new patients, 2) that we discourage the dependence on all schedule drugs (including medications such as Ambien, Xanax, etc) and will require seeking ways to help patients with their issues without the use of narcotic medications, and 3) we will screen all patients using the Arizona Controlled Substances Prescription Monitoring Program. By clicking below, you agree and understand our office policies regarding narcotic medications, and provide us consent to review the CSPMP database along with your Pharmacy Benefits Manager database.
Please list all of your current medications, including any over the counters you may be taking, along with dosage and frequency. If you are not currently taking any medications, please write NONE
Please list any allergies to medications you may have. If you have none, please write NONE
Family History (Father) *
Any family history for your father?
Family History (Mother) *
Any family history for your mother?
Family History (Sisters) *
Any family history for any sisters?
Family History (Brothers) *
Any family history for any brothers?
Do you currently smoke or vape? *
Did you previously smoke? *
Do you drink alcohol? *
Do you use drugs currently or have used them in the past year? *
If yes, then what have you used?
Please list any drugs you may have used with regularity in the past year.