Dr. Bias - Pre-Travel Consultation with Insurance

Thank you

Please fill out the intake form below

All your information is kept strictly confidential and 100% secure.
Do you need an interpreter for your appointment?

YesNo
Disclaimer: Please ensure that someone, preferably a family member, who speaks English is available to assist you throughout your appointment booking process.
Please select one of the preferred languages for your appointment.*
Select "Other" to type your preferred language. We will do our best to match your language preference.
Please type your preferred language.
Is this appointment for you or for your dependent?*

This appointment is for myselfThis appointment is for my dependent
Are you a returning patient?*

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Is your dependent a returning patient?*

YesNo
Patient Information
Patient name*

First NameLast Name
Pronouns
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Please enter the preferred pronouns
Date of birth*

MonthDayYear
Date
Sex assigned at birth*
Gender identity
Please select "Other" to provide the patient's preferred gender identity
Please enter the preferred gender identity
Email address*
example@example.com
Phone number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Placeholder Email
Health Insurance

Let's help you find the lowest cost option.
Does your dependent have a current/valid insurance?*

Yes, my dependent will use their insuranceNo, they're paying for themselves
Who's your insurance provider?
Please select "Other" to provide a different insurance provider.
Please enter your insurance provider.
Service date

MonthDayYear
Date

Is this a new concern or a follow-up appointment?*

New concernFollow-up appointment
Would you like us to try and match you with the last Doctor who saw you if he/she is available?*

YesNo
Would you like us to try and match your dependent with the last Doctor who saw your dependent if he/she is available?*

YesNo

Patient Information