CHOICES Med - telehealth appointment request

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Please call 718-786-5000 or book online here to schedule an on-site appointment at CHOICES.

Name*
Email*
Date of Birth:*

MonthDayYear
Phone Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
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When was the first day of your last menstrual cycle? *

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Approximately how far along are you in your pregnancy?*
To calculate, use the pregnancy calculator here.
When are you looking to be seen? *

MonthDayYear
Date
What is the best way to contact you? *
What is the best time to contact you? *
What are the best days to contact you? *
Is there any method of contact or at any time you NOT be contacted for privacy reasons? *
InsuranceSelf Pay
Insurance Name:*
Member ID*
Are you looking for funding support to help pay for your visit? If so, how much funding would you be requesting? *
Please verify that you are human*
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