*** Thank you for filling-out this appointment request form. We will try our very best to call you back as soon as possible with an available time, but please allow 1 business day. ***
5a. Primary BEST CONTACT phone # and able to leave messages.
If policy holder is different from the patient then name & birthdate information
Primary Insurance Information. Medicare, BCBS, UHC, Aetna, Cigna...
Secondary Insurance Information. Medicare, BCBS, UHC, Aetna, Cigna...
Request 1st and 2nd choice
Request 1st and 2nd choice. Option: *** First Available Doctor, *** Tom-Thuan K. Nguyen, MD (Internal Medicine), *** Mike-Huy K. Nguyen, MD (Family Practice), *** Lisa Chan, MD (Internal Medicine) *** Maria Nguyen, MD (Infection Disease-referral only)
Note: We require current vaccine record for children's visit. Physical are morning appointment because of fasting. *** Fasting mean NO FOOD and drink after midnight. WATER IS ALLOWED. No "black" coffee. Take your medication with water. Medication which require food, take those meds after doctor's visit and labs.
Please be Specific and UP Front. This will help us schedule enough time. How long have you been experiencing these symptoms? (hrs, days, or wks) Include symptoms: Fever, Chills, Weight changes, Pain (specify), Sore Throat, Headaches, Ear Pain, Eye Pain, Congestion, Cough, Shortness of Breath, Wheezing, Chest pain, Abdomen Pain, Constipation, Diarrhea, Joint swelling, Joint pain, Muscle weakness, Rash, bleeding, Reason in hospital, etc.
NOTE: Once you are done, click submit and you should see a green messages "... successfully submitted". *** A RED messages is an error. You need to correct and then click submit. THANK YOU