REQUEST AN APPOINTMENT
If this is a medical emergency, please call 911 immediately. |
Our referral center will attempt to contact you on the same day of your appointment request or the following business day.
Our office highly respects your privacy. Contact information will NOT be shared or sold to any third parties under any circumstances.
* MANDATORY FIELDS |
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| PLEASE COMPLETE THE FORM BELOW |
| New Nephrology Consult Follow-up |
| PATIENT INFORMATION: |
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| * Name: |
(please enter your first and last name, and middle initial.) |
| * Address: |
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| * Date of Birth: |
dd/mm/yyyy |
| * Gender: |
Male/Female |
| * Health Insurance: |
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| Will you require an English-translator for your visit:
Yes
No |
| If Yes, for what language: |
| CONTACT INFORMATION: |
| If name is different from above, please enter your first and last name, and middle initial. |
| Name: |
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| E-mail: |
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| * Phone: |
XXX-XXX-XXXX |
| * The Primary Physician’s Name:
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| APPOINTMENT INFORMATION: |
| * Appointment Reason:
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| Other Appointment Requests:
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| Urgent Appointment Need:
Yes
No |
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| CONTACT US: |
Presbyterian Hospital Building
622 West 168th Street
4th Floor Room 124
New York, NY 10032 |
| Phone |
212.305.3273 |
| Fax: |
212.305.4981 |
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Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.
Determination for all urgent appointments will be made by provider after reviewing your Medical Records |
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