Clinical Appointment Request Form

Request an Appointment

First Name *

Last Name *

Phone Number *

Email Address *

Date of Birth *

Gender *

Marital Status *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Preferred Appointment Type: *

I am a: *

Past Medical History *

Reason for Visit / Primary Concern *

You will undergo further assessment by the doctor

Preferred Days: *

Preferred Time Window: *

How did you hear about Dr. Puri? *

Please specify your referral

Consent *

I acknowledge that this form is not for emergencies. Submitting this form does not establish a doctor-patient relationship until confirmed by the clinic. If this is an emergency, please call 911 or go to your nearest emergency room.
I consent to be contacted regarding appointment scheduling.
Dr. Paul R. Puri only accepts cash payment or credit card, but can provide documentation to assist reimbursement from your insurance company (super bill).

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