Name *

First Name

Last Name

Phone

(###)

###

####

Who is interested in becoming a patient? (Dr. Davis is currently only accepting newborns as new patients). *

Check all that apply.

Newborn Baby

Other Child

Other Adult

If you are currently pregnant, when is your due date?

MM

DD

YYYY

If you are currently pregnant, where do you plan to deliver your baby?

(This is a factor in how many newborns we can accept each month, depending on the scheduling needs).

Planned Homebirth

Planned Hospital Birth

If you are seeking care for an adult or older child, would you like to be added to the waiting list?

Yes

No

What type of insurance plan do you have? *

While we do not participate with any insurances, it is helpful for us to know if your insurance will actually be a barrier to care.

No Insurance

Private HMO

Private PPO

Private EPO

Tricare

Medicaid

Medicaid HMO (like some CDPHP, Fidelis)

Child Health Plus

Other

How Did You Hear About Me? *

Friend / Family Member

Midwife / Birth professional

Chiropractor

Internet Search

Dr. Green Mom Website

Dr. Sears Website

Functional Medicine Directory

Other (please specify):