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Here’s what we need you to complete and bring with you to your appointment.

New Patients

New patients must complete the Patient Information Packet and Medical History Forms before seeing a medical provider. Print and complete the form or forms below which are appropriate for you, and fax them to Good Samaritan Gwinnett at 678-280-6635 or bring them with you to your appointment.

New Adult Patient Packet / Paquete de Nuevo Paciente para Adulto
New Child Patient Packet / Paquete de Nuevo Paciente para Niños

Medical History Form / Formulario de Historia Médica

In addition to these forms, you are required to bring the following:

  • Proof of Income (check stub, tax return, unemployment letter, etc.)
  • Photo ID (driver’s license, passport, student ID, etc.)
  • All prescription medications you may be taking
  • If you do not speak fluent English, you must provide your own interpreter

Please arrive fasting (no food or liquids other than water after midnight the night before your appointment) if you are being seen in the morning for an annual physical. Patients should take their morning medications as indicated.

There is a minimum fee of $25 for all blood work; some tests are more expensive.

Review our Frequently Asked Questions here to better understand how our clinic works and what we expect from you.

Established Patients

If your health information has changed since your last visit to Good Samaritan, please complete the following form and fax it to 678-280-6635 or bring it with you to your appointment.

Update Personal Information Form for Established Patients / Actualizar el Formulario de Información Personal para Pacientes Establecidos

Medication Refills

Print and complete the appropriate medical refill request form below and fax it to 678-280-6635. You must complete the entire form in order to receive a refill. Your refill request must be provided to Good Samaritan Gwinnett no less than two weeks before you run out of medication.
Medication Refills Form – English
Medication Refills Form – Spanish

Patient Policies

Our patient policies are provided for review here.

“The staff of this clinic are true Good Samaritans. I believe everyone wants to help me.”

— Nanette F., patient

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