Medical/Surgical Appointment

Please fill out the form below to schedule your appointment.

Personal Information
First Name*
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Date Format: MM slash DD slash YYYY
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Address
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Apt.*
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Contact Information
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Primary Care Physician
Primary Care Physician Phone
Which Specialist?
- Evan Goldstein, D.O. - Proctology & General Surgery
- Matthew Lemer, M.D. - Urology (only at our NYC office)
- Steven Lavender - Pelvic Floor Therapy (only at our NYC office)
If you're interested in Evan Goldstein, D.O.
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Insurance Coverage
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Date Format: MM slash DD slash YYYY
Add Secondary Insurance Plan (optional)
Insurance Carrier
Policy Holder's Name
Policy Holder's ID
Policy Holder's Date of Birth
Date Format: MM slash DD slash YYYY
Reason for visit*
Financial terms and conditions*
Financial terms and conditions | HIPAA terms and conditions | Same-day cancellation fee, and late fee policies.
Financial terms and conditions*
- I agree to the financial terms and conditions
- I agree to the HIPAA terms and conditions
- I read and agree to our confirmation, same-day cancellation fee, and late fee policies.
News and exclusive offers
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