Form New Patient Demographic Information

my abs
By providing this you agree to be contacted via phone including text and voice messages.
ADDRESS
Could also enter "self pay" or "no insurrance available".
Could also enter "self pay" or "no insurrance available".
Type "not applicable" or "NA" if you dont have secondary insurrance.
Type "not applicable" or "NA" if you dont have secondary insurrance.
You can find this information on your insurrance card. Having the PCP information expedites the workflow. Can also type "not applicable or i dont have the info" to bypass this field.
You can find this information on your insurrance card. Having the PCP information expedites the workflow. Can also type "not applicable or i dont have the info" to bypass this field.
You can find this information on your insurrance card. Having the PCP information expedites the workflow. Can also type "not applicable or i dont have the info" to bypass this field.
You can find this information on your insurrance card. Having the PCP information expedites the workflow. Can also type "not applicable or i dont have the info" to bypass this field.
Please tell us in few words the reason for this appointment. Thank you.

Dear Patient, 

Thank you for scheduling your elective consultation with us. Please note that this appointment is for a future date and is not intended for emergencies. If you have a medical emergency, please proceed directly to the nearest Emergency Room or call 911. 

We look forward to meeting with you at your scheduled appointment. If you have any questions or need to reschedule, please contact our office at 9178532781 or resend another submission of this form. Best regards, Marius Calin MD FACS FASMBS - MC Surgical Expertise LLC

Disclaimer: By entering your information into this web form, you agree and acknowledge the following: Accuracy of Information: You certify that all information provided is accurate to the best of your knowledge. Consent for Use: You consent to the use of this information by Dr. Calin and MC Surgical Expertise for the purpose of including but not limited to medical records management, appointment scheduling, etc. Data Security: You understand that while Dr. Calin and MC Surgical Expertise will take reasonable measures to secure your information, data transmitted over the internet can never be guaranteed to be fully secure. Voluntary Submission: Submission of this form is voluntary, and you have the option to refrain from completing it or providing certain information. Contact: For any questions or concerns regarding the handling of your information, please refer to our Privacy Policy or contact Dr. Calin and MC Surgical Expertise at [email protected] or fax: (917) 281-3303. By clicking "Submit" or otherwise submitting this form, you confirm that you have read, understood, and agree to these terms.