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Advanced Internal Medicine Group
Primary Care Internal Medicine | AIM Housecalls | Marijuana Medical | Spravato REMS Center
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New Patient Appointment Request
Our team will review your information and reach out to you to explain your benefits with us as well as help schedule your first appointment.
Patient Last Name
*
Your answer
Patient First Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Contact Number
*
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Cell Number
Your answer
E-mail Address
*
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Primary Insurance
*
If you do not have insurance please enter "Self Pay"
Your answer
ID#
*
If no insurance please enter "N/A"
Your answer
Secondary Insurance
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ID#
Your answer
Referred By
*
Choose
Physician Referral
Existing Patient
Google
Yelp
Facebook
Newspaper Ad
MarijuanaDoctors.com
Other
Office Use - Referral Info
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Requested Doctor
Dr. Leon Schwechter
Dr. Javier Morales
Dr. Neena Shah
First available doctor
Other:
Reason for Appointment
*
New Primary Care Physician
Acute
Pre-op
Medical Marijuana Consultation
Spravato Consultation
Other
Required
For Medical Marijuana Only: What is your diagnosis which you are looking to utilize Medical Marijuana for?
Option 1
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For Harborside Residents Only: Do you currently have a PCP?
Your answer
For Spravato Patients Only: Do you currently have a doctor suggesting this treatment? Or how did you learn about Spravato?
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Your name and relation to patient
*
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Notes (For office use only)
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