Please complete the secure form below to request a non-urgent new or established patient visit with one of our providers at one of our convenient locations. You can expect to be contacted within 24 hours of submitting your request. If your need is of a more urgent matter, please contact us by phone.

If you are a new patient,  you can conveniently download our new patient registration forms and information through our web site. 

* Denotes Required Information
Patient Information
First Name: *
Middle Initial
Last Name: *
Zip:
Date of Birth: *	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028
Last 4 digits of social security number : *
Daytime Phone: *	format: xxx-xxx-xxxx
Best time to contact you *	Select a preferred contact time Morning Afternoon Evening
Appointment Information
Patient Status:	Select patient status I am a new patient. I am an existing patient.
Type of Appointment:	Select appointment request.. Schedule A New Appointment Schedule Follow Up Appointment Cancel Existing Appointment Reschedule Existing Appointment
Referring Physician:
Desired Location: *	Select a location.. Rochester Irondequoit Pittsford Brockport
Preferred Time: *	Select a preferred timeframe 48 - 72 Hours One Week Two Weeks Three Weeks For Urgent Appointments within 24 Hours, please contact us by phone.
Provider:*	Please select a provider.. Dr.John Ventura Dr.Brian Justice Dr.Jeremy Lee Dr.William DeSandis Dr.Eric Perlman
Other Information
What insurance do you have?:*
Please indicate any additional information or special requests: