Patient Information

New Patient Forms

For your convenience we have provided our patient information forms online. Click on the link(s) below to access the forms. After clicking the link, a browser window will open. After the link opens, click on the ‘PRINT’ icon.

Please fill out all forms completely and bring them to our office.  Please bring a photo ID and your insurance card(s).  It is recommended you arrive at least 15 minutes prior to your visit. If you prefer, you may fax the forms to our office at (480) 892-2243.

New Patient Medical History Form

Medical Treatment Agreement

Personal Demographics


To make an appointment, or make changes to an existing appointment, please call (480) 892-1540.  Please give us 24 hours notice if you need to change or cancel your appointment.


We accept a variety of health plans including those listed below. If you have questions about insurance coverage, please contact us at (480) 892-1540.

  • America’s Choice Provider Network (ACPN)
  • Blue Cross Blue Shield
  • Cigna
  • Contract Analysis Systems/Viad – PPO
  • Coverdell and Company, Inc.
  • FedMed
  • Galazy/Managed Care Incorp (MCI) – PPO
  • Integrated Health Plan – PPO
  • JCPenney Financial Services Inc./ Plan Plus
  • Medicare
  • National Association of Preferred Providers (NAPP)
  • National Preferred Provider Network
  • Three Rivers Provider Network + Worker’s Compensation
  • UnitedHealthcare

Hospitals/Medical Centers

Dr. Ellsworth has credentials at the following medical facilities:

  • Banner Desert Medical Center
  • Banner Gateway Medical Center
  • Banner Ironwood Medical Center
  • Gilbert Hospital
  • Mercy Gilbert Medical Center (pending)