PRINE Health Form Requests
Please fill out the form below. You can also reach us by phone at (516) 951-1110. We will get back to you as soon as possible.
Please Select Your Choice
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Make Appointment
Contact For Information
Job Applications
Other
Name:
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First Name
Last Name
Contact Number:
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Format: (000) 000-0000.
E-mail:
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example@example.com
How did You Hear About Us:
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Please Select
Google Ads
Google Organic
Google Business Profile
Social Media
Referral
Existing Client
Which Type of Care Do You Need?
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Nephrology
Rheumatology
Podiatry
Vascular
Primary Care
Endocrinology
Urology
IV Wellness
Other
Provider Name (Unsure? Find provider names here or leave blank.)
Preferred Day of the Week
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Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Availability
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What is the Reason for Your Visit?:
Which is Your Preferred Office Location?
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Nephrology - Manhasset
Nephrology - Bellmore (NN)
Nephrology - Bellmore (IRP)
Nephrology Rockville Centre
Nephrology - Rockville Centre
Nephrology - Freeport
Nephrology - Roslyn
Primary Care - Bellmore
Primary Care - Garden City
Primary Care - Hicksville
Primary Care - Manhasset
Primary Care - Plainview
Dermatology - Commack
Endocrinology - Great Neck
Infusion
Rheumatology - Commack
Rheumatology - Plainview
Rheumatology - Garden City
Podiatry - Great Neck
Podiatry - Great Neck Family Foot
Podiatry - Port Washington
Podiatry - Rockville Centre
Podiatry - Hicksville
Podiatry - West Islip
Transplant - Garden City
Urology - Hewlett
Urology - Plainview
Vascular - New Hyde Park
Vascular - Great Neck
Vascular - Bellmore
IV Wellness - Bellmore
IV Wellness - Plainview
IV Wellness - Garden City
Other
Reason for Inquiry (Optional)
Billing Inquiry
Human Resources or Jobs
Patient Portal
Provider Interest
Independent Practice Association
Resting Metabolic Rate Testing
Telehealth
Feedback or General
Other
Do You Have Any Questions or Comments Regarding Your Visit?:
Job Application
Position Of Interest:
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Endocrinologist
Medical Biller
Nephrologist
Medical Receptionist
Medical Provider
Administrative and Leadership Role
Care Manager
Other
If Other, Please Specify the Position:
Submit CV
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