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Patient Requests: Request Appointments, Send Messages, Prescription Refills

Use this form to request an appointment, inquire about a bill, or renew a prescription. After completion, it will be electronically
sent to our office. Our staff will contact you within the next 48 hours.

DO NOT USE THIS FORM TO REQUEST MEDICAL ADVICE FOR URGENT CONDITIONS OR FOR EMERGENCIES.
THESE REQUESTS SHOULD BE CALLED TO THE OFFICE (718-543-3636) AND DISCUSSED DIRECTLY WITH OUR STAFF.


* Indicates Required Fields

PATIENT INFORMATION:

*Supply either a home number or cell number:
*Last Name *Home Phone
*First Name *Cell
Address Work Phone
City *Health Insurance
State *Ins. ID #
Zip *Primary Doctor
Email *Doctor Phone #

MESSAGES:
*Name *Phone
*Address *Email

Type your message below:


APPOINTMENT REQUESTED WITH:
Isadore Gutwein, MD
Robert Sable, MD
Michael Ader, MD

David Stein, MD
Daniel Reich, MD		 Sean Byrne, RPA-C
Patricia Halton, RPA-C

APPOINTMENT REQUESTED AT WHICH BRONX LOCATION:

Main Office: 3765 Riverdale Ave (Providers: Our entire staff)
Belmont Medical: 2371 Arthur Avenue (Providers: Robert Sable, MD; Sean Bryne, RPA-C, Patricia Halton, RPA-C)
Uptown Medical: 305 E. 149th Street (Providers: Michael Ader, MD and Patricia Halton, RPA-C)
Concourse Office: 2960 Grand Concourse (Providers: Daniel Reich, MD)

If you have requested an appointment: Our office staff will call you to make an appointment. If needed, please obtain any referral forms or authorization for this appointment from your primary care MD and bring them with you to your appointment.
If you have asked a question: We will call you back as soon as we have an answer for you.
If you have requested a prescription: Prescription refills will be mailed to you unless you request otherwise. Please include the name of your mediation, the dose, how often you take it and for how many days you need a refill. To receive a controlled medication, we may have to ask you to come into the office.
 
PRESCRIPTION REQUEST:
*Complete Patient Information Section above.
Pharmacy   Physician  
Phone   Fax  
Do you want your prescription: Mailed to you Faxed to pharmacy

Prescription #1
Medication  
# Pills Per Day # Days
Strength # Refills



Prescription #2 (If needed)
Medication  
# Pills Per Day # Days
Strength # Refills

 

Prescription #3 (If needed)
Medication  
# Pills Per Day # Days
Strength # Refills