SCHEDULE ORTHOPEDIC SURGERY 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 DR. VIKAS VARMA, MD - Manhattan Orthopedics Location:

Manhattan (Midtown West) - 57 West 57th Street 15th Floor, New York, NY 10019

QUEENS (Astoria) - 27-31 Crescent Street Astoria, NY 11102

BROOKLYN (Brooklyn Heights) - 41 Clark St. Brooklyn, NY 11201

FIRST AVAILABLE APPOINTMENT / ANY LOCATION

THIS ORTHOPAEDIC SURGERY RX IS ONLY FOR DR. VIKAS VARMA, MD AT MANHATTAN ORTHOPEDICS

FOR MEDICAL TEAM APPOINTMENTS CLICK BELOW: