**WE ARE CURRENTLY EXPERIENCING TECHNICAL DIFFICULTIES WITH THE FORM SUBMISSION BELOW.***

IF YOU WOULD LIKE TO BECOME A NEW PATIENT AT OUR OFFICE, PLEASE EMAIL US AT

VANZANTMEDICALGROUP@GMAIL.COM

AND INCLUDE THE REQUESTED INFORMATION BELOW IN YOUR EMAIL.

THANK YOU!!

Please complete the form below!  

Dr. Van Zant works to ensure that she schedules only patients whom she feels she or her nurse practitioner would be able to provide exceptional care. Because of this, all persons interested in becoming a patient at Van Zant Medical Group, S.C. must provide a concise summary of the medical concerns he/she wishes to be seen for.

If Dr. Van Zant feels that our office is a good fit for the patient’s medical concerns, she will assign the patient to be seen by herself or her nurse practitioner. The patient will then contacted regarding an appointment time.

Our practice does not act as a primary care office, nor provide any traditional primary care services. Our patients are expected to maintain a separate primary care doctor for urgent needs and traditional doctor’s visits.

**Important considerations**

• If the patient is scheduled with our nurse practitioner, the patient will continue to see only her and will not transfer to Dr. Van Zant, as our nurse practitioner maintains her own panel of patients.
• Please note that submission of information does not guarantee a patient appointment.
• The initial visit at Van Zant Medical Group, S.C. typically lasts 90 minutes and most patients are scheduled as such. However, if your medical concerns are complex, you may be scheduled for a two hour initial visit.
• If you are scheduled for a new patient appointment, you will be asked to provide a $250 deposit at the time of scheduling. This deposit will be applied to your first visit balance.
• Once you are scheduled for a visit, you will be sent the payment policy and prices to review and sign within your patient portal.
• The patient will typically receive an answer regarding scheduling within 2-4 weeks of submitting the medical summary.
• If you have not heard from our office after 4 weeks, we invite you to call our receptionist at 309-621-9580 to check on your request.

If you are interested in becoming a new patient, please complete the following form:

Please DO NOT attach or include detailed prior lab work.