Medical/Surgical Appointment

Personal Information

Legal First Name*

Legal Last Name/Family Name*

Preferred Full Name

Date of birth*

Gender*

Preferred Pronoun*

Address

Street Address*

Apt.

City*

State*

Zip Code*

Contact Information

Primary Phone*

Email*

I prefer to be contacted by*

Primary Care Physician

Primary Care Physician Phone

Insurance Coverage

Insurance Carrier*

Policy Holder's Name*

Policy Holder's ID*

Policy Holder's Date of Birth*

Add Secondary Insurance Plan (optional)

Insurance Carrier

Policy Holder's Name

Policy Holder's ID

Policy Holder's Date of Birth

PLEASE BRIEFLY DESCRIBE THE REASON FOR YOUR VISIT, INCLUDING SYMPTOMS

PLEASE BRIEFLY DESCRIBE THE REASON FOR YOUR VISIT, INCLUDING SYMPTOMS*

Do you live outside of the NYC area?*

Would you prefer to schedule a Virtual Consultation before an in-person visit?*

If you end up requiring a surgical procedure, would you prefer:*

To receive the surgical procedure the same week as your consultation (all in one trip), or
Schedule a return trip for the surgical procedure

Financial terms and conditions*

Financial terms and conditions*

I agree to the financial terms and conditions
I agree to the HIPAA terms and conditions
I read and agree to our confirmation, same-day cancellation fee, and late fee policies
I agree to the code of conduct terms and conditions

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