Patient registration

Complete this secure form before your first visit at Kennesaw Primary Care. Fields marked with * are required.

Step 1 of 9·Patient registration

11% complete

1. Patient information
2. Insurance
3. Emergency contact
4. Agreement & consent

Patient information

Demographics and contact details

First name *

M.I.

Last name *

Date of birth *

Social Security #

Sex *

MaleFemaleOther / Prefer not to say

Cell phone *

Work / daytime phone

Home phone

Email address *

Home address — street *

City *

State *

ZIP code *

Race *

Select race…

Ethnicity *

Hispanic or LatinoNot Hispanic or LatinoUnknown

Primary language

Marital status *

SingleMarriedDivorcedSeparatedWidowed

Personalized primary care and psychiatry built around long-term relationships, clear plans, and direct access to your team.

Contact

6110 Pine Mountain Road, Suite 201Kennesaw, GA 30152
+1 404-589-3366
Fax +1 877-682-6790
info@kennesawpcp.com

Top Doctors 2026
Concierge Excellence
Trusted Local Care

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Specialties

Preventive & routine care
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Patient Tools

Primary Care Patient Portal
Psychiatry Patient Portal
Patient Registration

Kennesaw Primary Care, operated by Peachtree Health Group, LLC, and Kennesaw Psychiatry, operated by Atlanta Psychiatric and Therapy Center, LLC, are separate and independently operated healthcare practices. Shared branding, facilities, website, telephone systems, or administrative resources do not create a partnership, joint venture, agency, employment relationship, or common ownership between the practices. Each practice is solely responsible for its own providers, services, medical records, billing, privacy practices, personnel, and operations.

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