Step 3: Patient Information

Please provide your information to complete your appointment booking

Personal Information

First Name *

Last Name *

Email Address *

We'll send appointment confirmations and reminders to this email

Phone Number *

Date of Birth *

Gender

Contact Preferences

Preferred Contact Method *

Email - Best for appointment confirmations and reminders

Phone - For urgent updates and personal communication

Text Message - Quick reminders and updates

Insurance Information

ℹ️ Insurance Coverage: We accept most major insurance plans. Please bring your insurance card to your appointment. If you don't have insurance, we offer competitive self-pay rates.

Do you have health insurance?

Yes, I have health insurance

No, I will pay out of pocket

Health Information

What are your primary health concerns? *

This helps your doctor prepare for your visit

Do you have any known allergies? *

Food allergies (nuts, dairy, eggs, etc.)

Drug/medication allergies

Environmental allergies (pollen, dust, pet dander)

No known allergies

Privacy & Data Security

Your information is protected by HIPAA and our strict privacy policies. We use industry-standard encryption to secure your data and will never share your personal information without your consent.