Request an Appointment

  • Please allow up to 2 business days for your appointment to be scheduled (some delays may be experienced due to COVID-19)
  • If you would like to schedule an appointment sooner, please call the doctor's office

Screening & Travel Questions

Step 1 of
In the last month, have you been in contact with someone who was confirmed or suspected to have Coronavirus / COVID-19? *
Do you have any of the following symptoms? (Please check all that apply.) *

Have you traveled internationally in the last month? *
Please list all of the countries you have visited in the last month. Also list the start date (month/day/year) and end date (month/day/year) you were in each country. *
Is there a specific doctor you're requesting? *
If yes, please provide name *
Please describe the type of doctor you need and the issue you are experiencing *
If available, and appropriate for your visit reason, would you prefer to see a doctor via a video visit or a telephone visit instead of an in-person appointment? *
Appointment preferred days and/or times
Country of residence *
Patient's first name *
Patient's middle name
Patient's last name *
Date of birth *
Patient's gender *
Patient's address *
City *
State *
Postal code *
City code *
Country code *
Phone number *
Email address *
Confirm email address *
Are you the patient? *
Your name *
Your phone number*
Your email address *
Country of residence *
Your relationship to the patient *
What is your diagnosis? *
What date would you like the appointment *
Are you a self-paying patient? *
Do you have health insurance? *
If yes what is the name of your insurance?*
Have you notified your insurance of this consult/procedure? *
Health insurance plan name *
Health insurance type *
Member ID number *
Group number
Insurance's customer service phone number
Is the patient the subscriber? *
Name of the subscriber *
Relationship to patient *
Subscriber Date of birth *
Employer name *
How did you hear about us? *
If Other, please specify *
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Please be aware, submitting this form does not guarantee your appointment is scheduled.

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