Become A Patient

Patient Information

First Name Last Name Gender Date of Birth Phone Number Email Address Address City & State Zip Code

Insurance Information

Please provide accurate insurance information so that we may verify our providers are in network with your plan.

Policy Holder Full Name Policy Holder Date of Birth Primary Insurance Plan Name Primary Insurance Member ID Primary Insurance Group Number Secondary Insurance Plan Name Secondary Insurance Member ID Secondary Insurance Group Number

Patient Medical History

Current Medical Problems/Reason for Seeing Doctor List of Current Medications Current Primary Care Physician

Do you have any history of TB? Do you currently have a work or Motor Vehicle Accident (MVA) related injury or illness? Where did you hear about TIMA? Preferred TIMA Physician

New Patient Information Form

Patient Information

Insurance Information

Patient Medical History

Contact Us

Important Links