New Patient Appointment Form

Hello and welcome to our practice. 

  • There are three ways to fill out the forms we require:  Print and fill out the following pages and bring them with you to your appointment; or you can fill them out below and submit online; or we can mail the forms to you directly.                                                                                                
  • We will call you to confirm your appointment 24 hours in advance.                                                                                 
  • Please arrive 10 minutes early. Please find a comfortable spot to wait, either on the bench in front of the office or in the waiting room inside the front door of the building. Your practitioner will find you when it is your appointment time.
Appointment time Provider Location
  Diane Dickinson, MD Arcata
    Crescent City
     
  Lorraine Carolan, PA Garberville

Appointment Cost:  For new patients, a payment of $120 (money order, or cash) is due at the time of your visit.

Please make your money order out to North Coast Medical (be sure to include your name and appointment date on the money order).

Cancellation policy:

Call us as soon as possible if you must cancel. 

No-Show Policy: If you miss your appointment and fail to call us, a $20 no-show fee will be due PRIOR to your rescheduling an appointment.

APPOINTMENT LOCATION:

Arcata: 1448 G Street, in the former garage attached to North Coast Chiropractic Office.  The closest cross Street is 14th.

Crescent City: 1080 Mason Mall, Suite 8B, just off Front Street between K Street and Price Mall.

Garberville: Redwood Wellness Group, 867 Redwood Drive, Suite D.

Send all written correspondence to our mailing address:

North Coast Medical
P.O. Box 1127 Arcata, CA 95518

Please arrive 10 minutes early for your appointment. Be prepared for your appointment by filling out this packet prior to arriving.

Worker’s Compensation and Disability evaluations are very important. If you have these things please bring a copy to your appointment.

We do not review XRAYS. Please do not bring or arrange to have XRAYS sent to our office.

Your evaluation will require approximately 20 minutes.

A follow-up will be necessary, in most cases, within a year of this exam. You must call our office to schedule a renewal appointment. It is your responsibility to keep your 215 status current and up to date.The validity of any advice or opinion rendered is subject to compliance with all applicable laws, consistent with your symptoms and/or diagnoses. Diane Dickinson, MD
 

Please fill out the ENTIRE form.  When you finish one section, expand the next section and fill out any applicable fields.

 

All Rights Reserved 2015 North Coast Medical