Appointment Request Form - EunJoo Lee, MD

Appointment Request Form
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Age Confirmation*
Please review and make sure this is the correct age of the patient. If not, please correct the date of birth.
Parent/Guardian Name*

First NameLast Name
What is your email address?*
example@example.com
What is your mobile phone number?*
Please enter a valid phone number.
Reason for Seeking Services*
Which services have been recommended to you?*

Outpatient Therapy or PsychiatryIntensive Outpatient ProgramPlease help me decide
What services are you looking for?*

Diagnostic EvaluationPsychiatric Medication EvaluationIndividual TherapyParent Therapy
How did you hear about my practice?
Please Select Your Insurance Carrier*
Dr. EunJoo Lee does not take insurance for services. She will provide a superbill on request, which you may submit to your insurance for possible partial/full reimbursement.*

I acknowledge
After this form is submitted, Dr. EunJoo Lee will contact you directly for a free 10 minute consultation and to answer any questions.
What is the best time for this phone call (Monday-Friday 9am-4pm)?*
Should be Empty: