Request an Appointment

Schedule Your First Appointment

Schedule a free 10-15 minute consultation call now if you have any questions before joining. If everything is clear based on what you have read so far, you can also schedule your appointment below!

Already a patient? Please login to the Patient Portal below.

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.

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.

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.