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Book Your Screening Colonoscopy Now

img page title1 Book Your Screening Colonoscopy Now

First Name:

Last Name:

Home Address:

City:

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Home Phone:

Cell Phone:

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EXT:

Home Address:

Date of Birth:

Employer Name:

Occupation:

Employer Address:

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Primary Insurance:

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HMO?

Authorization Required?

Co Pays:

Name of Medical Group:

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In Case of Emergency Call Name:

Phone#:

Relationship:

I here by authorize payment of medical benefits billed to my insurance to:


I HEREBY ACCEPT RESPONSIBILITY FOR PAYMENT FOR ANY SERVICE(S) PROVIDED TO ME THAT IS NOT COVERED BY MY INSURANCE.I ALSO ACCEPT RESPONSIBILITY FOR FEES THAT EXCEED THE PAYMENT MADE BY MY INSURANCE,IF THE PRACTICE DOES NOT PARTICIPATE WITH MY INSURANCE. I AGREE TO ALL CO-PAYS, DEDUCTABLES AND CO-INSURANCE AT THE TIME OF SERVICE.

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Date:


I'm glad I was able to find someone like Dr. Desai using this site. I was looking for someone who specialized in this field and I'm glad that this website was able to help me locate him with ease.

Jorge M. - 4/26/2012

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