Telemedicine Appointment Form

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M-F 6-9 p.m., Friday 9 am - 7 pm, Sat 11-7 p.m. VISITS BY APPOINTMENT ONLY! 230 Hilton Ave, Hempstead NY 11550. From the Hempstead Bus Terminal! Go to Jackson St, turn right on Franklin St, left on Atlantic Ave, then right on Hilton Ave.The clinic is at 230 Hilton Ave, Suite 105. COMPLETE THE JOT-FORM BELOW
Types of Visits
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a health insurance?
Which Insurance You Have?
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Appointment
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