Upstate University Hospital
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谢谢你考虑上州的照顾. 我们在这里照顾你在任何年龄和任何情况下改善你的健康. Please complete this form, 我们将向您发送最符合您需求的医疗服务提供者的信息. 如果一个天博app的供应商不能满足你的需求, 我们会将社区内的其他供应商推荐给您. 供应商不支付我们的转介或付费参与我们的转介服务.

有关特定医疗保健提供者的更多信息, 条件或治疗方案, visit http://orhpvrq8.guancall.com/healthcare/providers/

请不要使用此表格向医生发送咨询请求或个人电子邮件.)

Fields with * are Required

Patient Information

要去看医生的人.

*这个病人以前在上州医院看过吗? Yes No

*First Name:

Middle Initial:

*Last Name:

*Date of Birth: (mm/dd/yyyy)

*Phone Number: (000-000-0000)

*Email Address: (someone@somewhere)

Street Address:

City:

State:

Zip Code:

*Insurance Plan: (如无保险，请输入“NONE”)

Contact Person

填写此表格的人.

*我提交这个请求是为了我的 (如果是Self，可以跳过以下内容)

First Name:

Last Name:

Phone Number: (000-000-0000)

Email Address: (someone@somewhere)

Doctor/Area of Interest

*Refer To/Area of Interest:

Or Find a Doc

*Referring Physician Name: (全称，如无，请输入“无”)

Additional Information

*Message/Comments:

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Upstate University Hospital
请求预约/转诊

Chat with a Representative

Diversity Lecture Series

Upstate University Hospital 请求预约/转诊

Chat with a Representative

Upstate University Hospital
请求预约/转诊