Patient Application

Apply to become a new patient at Seaside Wellness of Navarre.


In order to provide the quality & efficient care for your individual needs, we want to ensure patients & providers are a great match for care. Please provide the information requested below so we can determine if our team may be able to meet your healthcare needs. Our clinicians will review your application along with the information provided. If we feel as though we are able to meet your needs after reviewing your information, we will contact you in a timely manner with our decision. Please allow additional time for the review process of your application due a high volume of new patient applications.

In an attempt to remain HIPAA compliant & within guidelines, please only complete this form if you are applying as yourself or a direct family member of the intended patient. If you are a provider or medical office, we ask that you instruct your patient to visit our website & apply for themself. Any applications submitted by or suspected to be submitted by providers or medical offices will be discarded of immediately.

Thank you, 
Seaside Wellness Staff

Patient Information:

Insurance:

Please include the insurance policy holder's relation to the patient (self, child, spouse, other), the policy holder's legal first & last name, the policy holder's date of birth, & the assigned sex at birth of the policy holder.
If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).
If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).
Please include the insurance policy holder's relation to the patient (self, child, spouse, other), the policy holder's legal first & last name, the policy holder's date of birth, & the assigned sex at birth of the policy holder.
If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).
If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).

Medical History:

Please be advised that per clinic policy, we only prescribe ONE (1) controlled substance per patient at any given time.
If we do not receive consent to contact current provider for medical records, we may not be unable to accept your application.
If we do not receive consent to contact previous provider for medical records, we may not be unable to accept your application.

Additional Questions:

Please select the provider you prefer & we will take this preference into consideration.
Not being an active participant &/or being noncompliant in care plans may result in discontinued services & dismissal from the practice at the degression of the provider.

Terms of Service