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Bringing LIFE Back to Your YEARS!
SCHEDULE NEUROLOGY APPOINTMENT
Please complete the form to be scheduled in the comfort of your home!
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Referring Doctor:
*
Park Avenue Medicine and Surgery / NYC PAIN SPECIALISTS
What is the reason for your visit? (Please let us know the reason for your visit, whether it be a consultation, specific condition, or otherwise.)
*
Date of Birth: (ex: Month, Day, Year: January, 01, 1990)
*
MM
DD
YYYY
Name of Insurance * If you are a worker's compensation patient, you may write "worker's compensation" [If paying out-of-pocket please indicate]:
*
Member ID *
*
NAME and DOB of Primary Card Holder:
*
Preferred Location:
*
Please select the preferred Outpatient Neurology - Brain Health Care Location:
Manhattan (Midtown) - 150 East 58th Street, 9th Floor (Annex Building), New York, NY 10155
Manhattan (Inwood) - 26 Sherman Ave Suite 1B-C New York, NY 10040
Bronx - 2356 University Ave, Bronx, NY 10468
Brooklyn (Downtown) - 50 Court Street, # 508A Brooklyn, NY 11201
Brooklyn (Brooklyn Heights) - 160 Montague Street, 4th Floor Brooklyn, NY 11201
Queens (Jamaica Estates) - 175-43 Hillside Avenue, Suite 1A Jamaica Estates, NY 11432
Staten Island - 11 Ralph Place, Suite 217 Staten Island, NY 10304
Long Island (Nassau) - 2001 Marcus Avenue, Suite W170 Lake Success, NY 11042
Long Island (Nassau) - 1570 Old Country Road, Westbury, NY 11590
FIRST AVAILABLE APPOINT (ANY LOCATION)
THIS NEUROLOGY RX IS ONLY FOR Neuro Injury Care / Brain Health NYC
Thank you!
FOR MEDICAL TEAM APPOINTMENTS CLICK BELOW:
SCHEDULE MEDICAL TEAM - NEW PATIENT
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