Urgent New Patient Appointment

Patients Last Name

Patients First Name & Middle Initial

Date of Birth

Parent or Guardians Name

Cell Phone Number

Email address

Insurance Company

Member ID

Must be correct ID number or you will not be scheduled.

Group

Subscriber Name

Date of Birth

Secondary Insurance Company

Secondary Member ID

Group Number

Secondary Subscriber Name

Subscriber Date of Birth

What do you need to be seen for?

YOU MUST PROVIDE DETAILS if requesting an urgent visit. Our specialists triage all urgent requests appropriately. Examples: For nasal fractures; we must have date of incident and if it is displaced or non-displaced. Nasal packing removal; we must have date packing was placed and packing must remain for at least 72 hours. For sinus pain and ear pain, we must have medical treatments received such as medications prescribed by PCP and how long patient has been experiencing symptoms. Nose bleeds; how frequent are they, how long do they last? Please understand that we do not have any flexibility when working a new patient in quickly regarding location, time or physician seen.

Which day's work best for you?

NOT GUARANTEED FOR URGENT REQUESTS

Use the space below for any questions you may have.

If you are unable to upload the documents below, we can scan them during your appointment.

Insurance Card Front

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Insurance Card Back

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Imaging and/or Reports

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Referral and/or Insurance Approval

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