New Patient Request

Emergency Assistance

If this is an emergency, call:

Patient Information

**IMPORTANT- READ BELOW**

Once this form is fully filled out and SUBMITTED, our New Patient Coordinator will respond to you via EMAIL (within 3 to 5 business days) with your scheduled appointment time. It is VERY important you use an active EMAIL and that you check your email for the response. Also please fill out all information completely and accurately, not doing so will delay the process. We must have your insurance information AND a copy of your insurance card in order to schedule your appointment. If you do not have insurance and you plan on being "cash pay", please indicate "cash pay" in the insurance box. Thank you and we look forward to servicing you.

**Please be patient, we get multiple new patient inquiries per day. We will respond, via Email, with your appointment time and date as soon as humanly possible. Thank you for your patience.

First name

Last name

Sex

Male or Female

Marital Status

Single, Married, Divorced

Home phone number

Cell phone number

Email address

Date of birth (please enter CORRECT full DOB)

Home/Mailing Address (Please write FULL address with city and state)

Race (required for government census reporting)

White African American or Black American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Decline to Specify

Ethnicity (required for government census reporting)

Hispanic or Latino Not Hispanic or Latino

Primary Care Physician

Are you a patient of Joseph Tiscani, DNP?

YES NO

Medical History

Have you been referred to our Practice by a Physician?

Yes No

If yes, please name the Physician and the reason they referred you

Date of your last physical exam

What is your Primary Health Concern needing consult by an Endocrinologist?

Diabetes Type 1 Diabetes Type 2 Thyroid Dysfunction Osteoporosis Metabolic Syndrome (Weight) Menopause PCOS Other

Insurance Information (Please Upload a copy of your Insurance Card where indicated)

Please list Insurance Company and Policy Name, Group ID, Subscriber ID

Insurance Card (Front and Back) UPLOAD CARD HERE!

Add file

Please upload a file

Does your Insurance REQUIRE a REFFERAL to be seen by a Specialist? **if YES, you are responsible for a referral authorization number to be on file in our office prior to your first appointment

YES NO

Primary Insurance Subscriber

I am the Primary Insurance Subscriber Spouse, Parent or Other is the Primary Insurance Subscriber

If selected, please fill out subscriber name, DOB, and Address below

Primary Subscriber Name

Primary Subscriber Date of Birth

Primary Subscriber Full Address, including State and Zip (If different than patient)

Do you have a Secondary Insurance?

Yes

if yes, please upload a copy of your secondary insurance card below

Secondary Insurance Card (Front & Back)

Add file

Please upload a file

Do you have an Advance Care Plan

Yes

If yes, please upload your Advance Care Plan here

Advance Care Plan

Add file

Please upload a file

Do you have a Surrogate Decision Maker? You can designate a surrogate decision maker, such as a spouse, family member, friend or member of a faith community.

Yes

If yes, please name in space below

If no, please designate a surrogate decision maker in the space below

Surrogate Decision Maker

Please write full name above and relationship to you

Please list the medications you are taking. Include the dosage and amounts.

Do you have any allergies to medications? Please List

Any other information pertinent to your visit?

Medical Records Upload any Test Results or Medical records you feel would be helpful to us

Add file

Please upload a file

Appointment Preferences Please indicate your appointment preferences below. Your first appointment will be scheduled within the parameters of your appointment preferences. Submission of this form and preferences indicate that YOU DO want an appointment scheduled at our office. Once this form is submitted with all the required correct information, we WILL schedule your appointment and we WILL EMAIL you the date and time of your first appointment.

First Available Appointment

**only select this option if your schedule is clear and can truly make the first available appointment

Morning Appointment

7:30 AM-11:45 AM

Afternoon Appointment

12:30-4:45 PM (not available on Fridays)

Any Day of the Week

**only select this option if you are available any day of the week

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

**only morning appointments available (we are closed in the afternoons on Fridays)

Additional Appointment Preference Information (if needed)

Emergency Contact Information

Add another emergency contact

I undertand that by submitting this form to the New Patient Coordinator I am requesting a New Patient appointment at Diabetes and Metabolism Specialists. I also understand that my first appointment date and time will be communicated to me VIA the EMAIL address I have entered on this form. I understand that I will need to check my email in order to know when my first appointment has been scheduled. I also understand that I am required to be "web enabled" in Diabetes and Metabolism Specialists Electronic Medical Record System and I will get notifications regarding appointments, prescriptions, and access to the patient portal to communicate with my provider and office staff.

Yes No

If you selected "Yes" above, please click the blue button labeled "Submit to New Patient Coordinator" below.

(Please DO NOT submit this form if you are not ready to have an appointment scheduled at Diabetes and Metabolism Specialists)

Your information will be encrypted.