APPOINTMENT REQUEST

Form to request appointment

This is to be used only for appointment requests.
APPOINTMENT REQUEST

we will call you with a response and details
Name*

First NameLast Name
Email*
example@example.com
Appointment time preferred, Mondays are physical appointments and others are telemedicine *
Your Phone Number*
Please enter a valid phone number. Your number is used to communitcate with you and to prevent spammers from creating accounts that are fake. We also respect your privacy and we do not collect numbers to spam or mass market. This is solely to communicate with you via voice and text if you opt in below. We will never communicate personal confidential information here or sell your number. This is for the sole purpose of communicating appointments and related info. To remove simply email us at lugosurgicalgroup@gmail.com you can check our privacy policy below or in the website www.drlugo.com
PRIVACY POLICY*
option for texting and phone communications*

OPT IN TO BOTHOPT IN TO VOICE ONLY
Do you have health insurance?*

YESNO
If insurance please enter name*
Insurance ID *
this will help expedite and assure you are covered
Date of birth*

MonthDayYear
to match with your insurance
Reason for you appointment or any other information.
just the reason for you coming to see us
You can upload here your license and insurance cards to facilitate and expedite the benefits check. This is a secure form 100 percent

Cancelof
Should be Empty:

Form to request appointment