New patients

Patient admission

Tell us a little about yourself and our care team will call you to schedule your first mobile visit. We accept all major insurance, including Medicare.

First name

Last name

Date of birth

Phone

Email (optional)

Home address

Insurance provider

Member ID

Reason for visit

Medical records release

So we can care for you safely, we ask your permission to request your medical records from your previous doctor or clinic.

Previous doctor or clinic

Their phone or fax (optional)

I authorize Victory Primary Care to request and receive my medical records, including history, lab results, imaging, and medication lists, from the provider named above and any other provider involved in my care. I understand this authorization helps my care team treat me safely, and I may withdraw it at any time in writing.

Signature (type your full name)

Insurance card & photo ID

Take a photo or upload a copy of your insurance card and a photo ID (driver's license or state ID). Photos up to 10 MB each.

Insurance card

Photo ID