Which method is the best and MOST RELIABLE way to get in touch with you (you are sure to get the message promptly). PLEASE CIRCLE and note if there are specific times or days.

Please note: we are pleased to provide our patients with assignment (direct billing) from the insurance provider. It may be necessary for you to collect the details of your policy due to privacy. The more information we have, the more accurately we will be able to estimate possible out of pocket expenses for your required treatment.

Dr. Singer will thoroughly review your medical history, please list the following:

Please remember to advise us of any changes.

All information is kept strictly confidential in accordance with privacy regulations.