Phone numbers you would like us to use to reach you:

Location	Phone Number	Best time to call (from _ to _)
Home
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Cell Phone
Other

I wish to set up an:       Office visit            Phone consultation

I have no preference regarding the time of the appointment I would like the appointment as soon as possible I have a time preference: I would like the appointment at (Time):  on   Monday   Tuesday   Wednesday   Thursday   Friday

How did you learn about Dr. Rind?

Please tell us something in relation to your concerns:

Type of insurance? Private Medicare Medicaid HMO None Worker's Comp. This problem is under litigation

NOTE: We do not participate with any insurance plans including Medicare. We will provide a payment receipt for services that will be submitted to your insurance company for reimbursement. Dr. Rind has opted out of Medicare and therefore Medicare will not reimburse for these services.

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