Carolina TotalCare

Patient Intake Form

Welcome to our online Patient Intake Form. Please be as detailed as possible as this information will be sent directly to our office, speeding up your office visit and allowing us to better serve your healthcare needs. PLEASE OMIT THE "REASON FOR VISIT" SECTION. YOU WILL BE PROVIDED AN ADDITIONAL FORM IN THE OFFICE UPON ARRIVAL. (Simply, scroll to the bottom of this section and hit the Next Button.) Call our office at (704) 784-4445 to schedule your new patient appointment if you have not already done so. Thank you! We look forward to seeing you!

Who are you?