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Advanced Internal Medicine Group
Primary Care Internal Medicine | AIM Housecalls | Marijuana Medical
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New Patient Appointment Request
Patient Last Name
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Patient First Name
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Date of Birth
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Contact Number
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Cell Number
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E-mail Address
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Primary Insurance
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ID#
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Secondary Insurance
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ID#
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Referred By
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Physician Referral
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Office Use - Referral Info
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Requested Doctor
Dr. Leon Schwechter
Dr. Javier Morales
Dr. Craig Grobman
Dr. Neena Shah
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Reason for Appointment
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New Primary Care Physician
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For Medical Marijuana Only: What is your diagnosis which you are looking to utilize Medical Marijuana for?
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For Harborside Only: Do you currently have a PCP?
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Notes (For office use only)
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Your Name and relation to patient
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