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New Patients · New Jersey

Welcome to MyPremierMD.

Ready to get started? Jump straight to full registration below.
Not ready yet? Send us a quick message instead and we'll reach out to answer your questions first.

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What happens after you register

Your information goes straight to our clinical team

  1. Our team reviews your intake, including your medical history and the services you're interested in, before you're ever seen.
  2. We call or email you — usually within one business day — to verify your insurance coverage and answer any questions.
  3. We schedule your first appointment at whichever office works best for you, or as a telemedicine visit.
Ready now?

New Patient Registration

Complete this form and our team will contact you within one business day to confirm your appointment and verify your insurance. Required fields are marked with an asterisk — everything else can be left blank if it doesn't apply to you.

1 Personal Information

2 Contact Information

3 Reason for Visit

e.g. "Annual physical" or "Anxiety and trouble sleeping for the last few months"
If you'd like us to coordinate with your other providers, list name, specialty, and location.

4 Health Insurance

5 Medical History

Leave any of these blank if they don't apply to you.

6 Lifestyle

Helps us understand health risk factors. Leave any of these blank if they don't apply to you.

7 Family & Preventative History

8 Sexual Health

Sexual health is an important aspect of general health. These questions help us provide complete care.

9 Mental Health Screening

Over the last 2 weeks, how often have you been bothered by the following?

If you're having thoughts of harming yourself right now, please call or text 988 (Suicide & Crisis Lifeline) or go to your nearest emergency room.

10 Mental Health Background

Have you been given any psychiatric diagnoses? If yes, list them.

11 Medical MJ Consent

New Jersey's Medical Marijuana Program requires a specific consent for certification. Reviewing and agreeing here does not itself certify you — our provider will discuss your eligibility at your visit.

12 Additional Information

14 How Did You Find Us?

You can also call us directly at (908) 450-7002 for immediate assistance.

Thank you! Your registration has been received and is on its way to our clinical team. We'll reach out within one business day to verify your insurance and schedule your first appointment.
Submitting… Please wait while we process your information.

Not ready for the full form?

Send us a quick message instead and we'll reach out within 24 hours to answer your questions and help you schedule an appointment.

Thank you! We'll contact you within 24 hours to answer your questions and help you schedule an appointment.
Error: Something went wrong. Please try again or call us at (908) 450-7002.
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What are you interested in?

Prefer to call? (908) 450-7002