GENERAL PATIENT INQUIRY FORM
We do not treat pediatric cases (aged 17 and younger)
IF YOU HAVE A 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.
PATIENT FORMS
DOWNLOAD OUR
FILLABLE PATIENT HISTORY
FORM HERE.
Then e-mail or fax it to our office.
gcmw@dr.com or 631-923-2907
DOWNLOAD OUR
PATIENT HOME LOG
FORM HERE.
Then e-mail or fax it to our office.
gcmw@dr.com or 631-923-2907
DOWNLOAD THE
IVERMECTIN INFORMED CONSENT FORM HERE.
Then e-mail or fax it to our office.
gcmw@dr.com or 631-923-2907
NOTICE:
E-mail is not always secure and although we make every effort to keep your information private, our e-mail is with a 3rd party service. We cannot be responsible for its privacy or security, Submission of your information is your responsibility.
We have received a number of inquiries from patients that claim to have on-line pre-paid for consultations.
WE HAVE NO SUCH POLICY.
Please contact our office BEFORE you pay any fees.
We will make a tele-health appointment at which time you would be asked for form of payment.
Your form of payment will be charged AFTER your appointment.