GENERAL PATIENT  INQUIRY FORM

IF YOU HAVE AN MEDICAL/HEALTH EMERGENCY-

DO NOT HESITATE - CALL 911 or your primary care provider.


PRIVACY WARNING:  Do not e-mail this completed form unless you confirm that your e-mail is secure.  Also your e-mail goes through our e-mail service provider and although they say that it is secure, we cannot guarantee the security of your privacy.  If you are not comfortable with the e-mail system, simply leave out details such as your date of birth or other identifying information.  Please add some form of your name so we can recognize your form.  Thank you.

YOU CAN DOWNLOAD OUR PATIENT FORM HERE AND SEND

700 New York Ave, 2nd Floor
Huntington, NY 11743

PHONE: 631-547-4100

FAX: 631-923-2907