Welcome to Southern Medical Group

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Services Desired

Diabetes Management

Urgent Care / Sick Visit

Wellness Visit

Occupational Health

Department Transportation Physical

Hypertension

Routine Primary Care

Which location would you prefer?

Claxton, GA - Dr. Jesse Scott, Suzannah Williamson NP-C

Glennville, GA - Dr. Paul Thompson, Kelly Daus PA-C, Jessica Huggins FNP-C

Reidsville, GA (Coming 2025)- Carla Collins, FNP-BC

I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form. *

Please note that by signing this form you are consenting to record checks from the Prescription Drug Monitoring Program of Georgia

I Agree