Grand Valley Primary Care & Grand Valley Pediatrics
Falsifying or excluding any information about your medical history may result in your dismissal from any of the primary care practices listed below.
Blue Cross Blue Shield
Rocky Mountain Health Plans
Are you related to or applying with another family member?
If so, who? Who is their current primary care provider?
If patient is under 18, who is the responsible party?
Please list all other health care providers that you routinely see (doctor/specialty)
Medical history for the past 10 years
(This is important for finding a provider who is knowledgeable with treating any conditions you may have.)
Have you been a previous patient?
If so, why did you leave?
Please provide an accurate list of medications you are currently taking. Medication omissions may result in denial of application.
Are you willing to use Community Hospital?
Do you use any tobacco products?
If you have a preferred provider, please include their name here. You may also write any additional comments necessary for the practice.
Do you have a preference in provider?
No Preference - Whichever provider has the earliest openings for new patient appointments
Do you need a bilingual provider?
If so, what language?
How soon do you want to be seen?
Less than a month
Please do not use this area to contact us regarding your personal medical issues. Please call us with questions about your medications or medical treatment. This information is sent to a referral coordinator for new patient applications only. If you are a current patient, please contact your provider.