New Patient Packet — Adult
New Patient Packet — Adult
If you are 18 or older and coming to Be Well for the first time, this is the paperwork we need. It is a fillable PDF — type it on a computer or phone, save it, and email or bring it in. Completing it beforehand is the single biggest thing you can do to shorten your wait at check-in.
What’s in the packet
- Patient Information — name, date of birth, address and contact numbers, marital status, race, ethnicity, and preferred language (English, Haitian Creole, Spanish, Russian, or another you specify), your current primary care provider, a parent/guardian/caretaker or agency contact if one applies, an emergency contact, and your primary and secondary insurance including policy or ID number and policy holder.
- Authorization for Treatment — your consent for our providers to evaluate and treat you, signed and witnessed.
- Receipt of Rights and Advance Directives — acknowledges that you received the Patients’ Bill of Rights and records whether you have a health care proxy or living will.
What to bring to your first visit
- A photo ID and your insurance card.
- A list of the medications you take, including doses.
- Any records, imaging, or test results from another provider.
- If the visit relates to a workers’ compensation injury or a car accident (no-fault), the claim information — the packet has a place for it.
Download the Adult New Patient Packet (fillable PDF)
Prefer to fill it out here? Come fifteen minutes early and our front desk will help you through it. Questions before you arrive: (718) 253-9355.
