Virtual Appointment Request with Tabasum M.D.
Thank you for reaching out. Please answer all questions.
Please also note we will do our best to accommodate your date. But Dates are subject to their availablilty
Email address *
First and Last Name *
Your answer
Instagram Handle (ex: @Tabasum) *
Your answer
City and State of residence? (I am licensed to practice in New York State)
Your answer
Date of Birth *
MM
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DD
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YYYY
What treatment are you interested in? *
Your answer
What is your FIRST requested Date and time? (ex: March 31. 2pm EST) *
Your answer
Contact Phone Number *
Your answer
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