Print Envelope Share-alt ADHÉSION Formulaire d’adhésion +216 93 231 464 Filll in the form What's your insurance plan? Please select I'm paying for myself I'll choose my insurance later Aetna Blue Cross Blue Shield (BCBS) Cigna EmblemHealth (formerly known as GHI) EmblemHealth (formerly known as HIP) UnitedHealthcare UnitedHealthcare Oxford What's the reason for your visit? Please select Allergic Cough Annual Pediatric Checkup Asthma Blood Work Child with Fever Cholesterol / Lipids Checkup Diabetes Consultation Diabetes Follow Up Diabetic Foot Ear Infection Flu Flu Shot Frequent Urination Illness Pediatric Consultation Has the patient seen this doctor before? Please select No Yes Choose the type of appointment Please select In-person Video visit Select date Select time Please select 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm First name Last name Date of birth Sex assigned at birth Please select Male Female Email Message I accept the Terms of Service Book an appointment >