New Patient | Bluegrass Medical Associates

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Phone: 270-441-4850

Bluegrass Medical Associates

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New Patient Intake Form

First Name

Last Name

Email

Address

Phone

Date of Birth

**Currently not contracted with Medicaid insurance** Please enter your reason for visit. (Ex: establish care or primary problem)

Submission received, you will hear from a member of our staff in 1-2 business days!

Phone: 270-441-4850

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