New Patient Form

    Patient Information

    Your Preferred Pharmacy

    Your Insurance

    MEDICARE: No providers at Fritz Clinic provide Medicare services or Disability Medicare services. I understand that I cannot be treated under my Medicare at Fritz Clinic.

    I understand that any prescription I receive from a physician at Fritz Clinic will not be covered under Medicare.

    BLUE CROSS BLUE SHIELD: I understand that Fritz Clinic is a cash-only practice and is out of network with BC/BS. I understand that I may file my visit for reimbursement with BC/BS. However, all services provided by Fritz Clinic (in all locations) are out of network.

    By submitting this form, you are consenting to receive marketing emails from Fritz Clinic, You can revoke your consent to receive emails at any time by emailing us at with the subject "Remove Me From Future Emails".

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