Request an Appointment

Please complete the appointment request form below. This page supports new patients, established patients, sick visits, well visits, and USCIS medical exam requests. If insurance information is being used, please be ready to upload the front and back of the insurance card.

Appointment Type *

Reason for Visit *

Patient Type

First Name *

Middle Name

Last Name *

Patient DOB *

Month

Day

Year

Sex *

Name of Parent/Legal Guardian

Relationship to Patient *

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City *

State *

ZIP / Postal Code *

For this visit, will you be using your insurance benefits or paying out of pocket (self pay)? *It is insurance holder's responsibility to check that we are in-network for your plan.

Upload the front and back side of the patient's insurance card *It is insurance holder's responsibility to check that we are in-network for your plan.

Name of Primary Policy Holder *

DOB of Primary Policy Holder *

Month

Day

Year

Upload relevant files(eg. UC/ER/hospital discharge note, immunization records, etc)

Additional InformationUse this space to include additional information including other applicants for the USCIS medical exam. Include their names and date of birth.

Disclaimer: By accessing and using this website, you assent to these terms and conditions, our website privacy policy and medical disclaimer. This website does not provide medical advice and use of this website does not establish a doctor–patient relationship. Always consult with a qualified and licensed physician or other medical care provider. If you think you have a medical emergency, call 911 immediately or proceed to the nearest emergency room.