Lincoln Park Il – fyzical-appt.com

Is this for an initial eval or a followup? *Initial EvalFollowup

Request An Appointment Type *In ClinicTelehealthFree Screen

What kind of screening would you like? *In ClinicVideo-based

Will you be using Direct Access or a referral? *ReferralDirect Access (No Referral)

Please type your referring physician’s name.

Appt. Date *

Appt. Time (CST) *

Hours

Minutes

The time selected may not be available and will be confirmed by the clinic.

Patient First Name *

Patient Last Name *

Email Address *

Phone *

Gender *MaleFemale

Date of Birth *

Please add your insurance details. (Optional)

Take a picture of the the front and back of your insurance card and upload it here. or supply information below

Upload Front & Back of Card

Carrier

Plan

Member ID#

Additional Comments

Text Reminders?I am interested in receiving text reminders.

Acknowledgement of Request *I acknowledge this is only a request pending the clinic’s confirmation.