1715 S. Wells Ave. Meridian, Idaho 83642

New Patient Form

  • Insurance Information

  • Emergency Contact

  • For New Patients Only

  • Note: Collection of Race and Ethnicity: Organizations are not only required (per 45CFR170.302(a)) to collect race and ethnicity data, but should use the data to identify and measure race, ethnicity, and language-based disparities.
  • This field is for validation purposes and should be left unchanged.