Thanks for your interest in joining the practice!

Before proceeding to the main form, please check each box to acknowledge the following:

Dr. Davis does not participate with any insurances.

Payment is based on a monthly membership in the range of $75-150 per month per child.

Dr. Davis no longer accepts new patients over age 12 for primary care.

The practice is located in Malta NY and generally can not accept patients from over 90 minutes away for primary care.

First Name *

Parent's Name

Last Name *

Email *

Phone *

Preferred contact method *

Text

City *

State *

What are you looking for in a doctor? *

Why do you want to work with Dr. Davis?

Are you interested in: *

Who is interested in becoming a patient? (Dr. Davis is currently only accepting newborns and their siblings as new patients). *

Newborn (not born yet)

Child through age 5

Older child 5-18

Adult over 18

Check all that apply.

How old are each of the children you would like to register? *

If you are currently pregnant, where do you plan to deliver your baby?

Planned Homebirth

Planned Hospital Birth

(This is a factor in how many newborns we can accept each month, depending on the scheduling needs).

If you are currently pregnant, when is your due date?

Dr. Davis accepts children regardless of vaccine status or plans. For any older children, what is their past vaccine history? Check all that apply.

What are your vaccine preferences moving forward? Check all that apply.

What type of insurance plan do you have? *While we do not participate with any insurances, it is helpful for us to know if your insurance will actually be a barrier to care.

Please elaborate on anything checked 'Other' or anything else you feel it would be important for Dr. Davis to consider.

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