Thank you for your interest in becoming a new patient with Vigor Natural Health Clinic, please fill out the information below for each person you wish to schedule an appointment for, once submitted someone will contact you within 72 hours to schedule your appointment.

18+ PATIENT INFORMATION

Please fill in the following information for each person 18+ that you wish to schedule an appointment for.

Legal Name *
Legal Name
Please add your middle initial in the first name input.
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Choose the provider you would like to schedule with.
Please let us know the reason for the appointment.
Billing Insurance or Self Pay *
Payment will be collected at the time of your appointment.
POLICY HOLDER INFORMATION
Policy Holder Date of Birth
Policy Holder Date of Birth
If you have any additional questions or concerns about this form please place them here.

DEPENDENT PATIENT INFORMATION

Please fill in the following information for each person under 18 that you wish to schedule an appointment for.

Legal Name *
Legal Name
Please add your middle initial in the first name input.
Date of Birth *
Date of Birth
Address
Address
Choose the provider you would like to schedule with.
Please let us know the reason for the appointment.
Billing Insurance or Self Pay *
Payment will be collected at the time of your appointment.
Policy Holder Date of Birth
Policy Holder Date of Birth
PARENT INFORMATION
Person financially responsible for the dependent.
Parent/Guardian Phone Number *
Parent/Guardian Phone Number
If you have any additional questions or concerns about this form please place them here.