Request an Appointment

Tell us which type of care you are seeking and how to reach you. This form requests an appointment but does not confirm one. The practice will review your information and contact you with scheduling options and next steps.

Please provide only a brief description of what you would like help with. Detailed medical information will be collected through the secure patient portal after scheduling.

Already a patient? Please use the Patient Portal for appointment requests, refills, and clinical messages.

Practice Information

Patients Adults 18 and older

Payment Private-pay

Telemedicine New York, New Jersey d

In-Person New York, New Jersey d

Initial Evaluation 50 min | $350

Phone [Phone Number]

Email [Practice Email]

New Patient Appointment Request

First Name

Last Name

Date of Birth

Preferred Contact Method

Email Address

Phone Number

State of Residence

What type of care are you seeking?

Preferred Appointment Type

Preferred Time of Day

What would you like help with?

How did you hear about Empire Medical Wellness?

Name of Referring Professional or Organization

I understand that submitting this form does not establish a physician-patient relationship.

I understand that this form is not monitored for urgent or emergency concerns.

I understand that telemedicine appointments require me to be physically located in New York or New Jersey at the time of the visit.

I understand that Empire Medical Wellness is a private-pay medical practice.

Information submitted through this form is used to respond to your appointment request. Please review the Website Privacy Policy and Notice of Privacy Practices for additional information.

What happens after you submit the form

01

Request Review

The practice reviews the requested service, appointment preference, and location information.

02

Scheduling Contact

You receive available appointment options, financial policies, and secure intake instructions.

03

Intake Completion

Required forms and payment information are completed through the secure patient portal.

04

Appointment Confirmation

Your appointment is confirmed after the required scheduling steps are complete.

This practice is not an emergency service.

Do not use this form, email, or routine patient messaging for urgent or emergency concerns. Call 911, call 988, or go to the nearest emergency department if you are experiencing an emergency.