Language
English (US)
Spanish (Latin America)
Form to request appointment
This is to be used only for appointment requests.
APPOINTMENT REQUEST
we will call you with a response and details
*
first name
Last Name
Email
*
example@example.com
Appointment time preferred, Mondays are physical appointments and others are telemedicine PLEASE NOTE THESE ARE APPROXIMATE TIMES FOR !)) WE WILL CALL YOU IF THIS TIME WORKS OR NOT. WE TRY TO ACOMMODATE YOUR NEEDS. THANk YOU FOR UNDERSTANDING.
*
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
Format: (000) 000-0000.
PRIVACY POLICY
*
option for texting and phone communications
*
OPT IN TO BOTH
OPT IN TO VOICE ONLY
Do you have health insurance?
*
YES
NO
If insurance please enter name
*
Insurance ID
*
this will help expedite and assure you are covered
Date of birth
*
-
Month
-
Day
Year
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
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