New York, NY 212.673.2721 | Poughkeepsie, NY 845.471.1354
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This form is to be completed ONLY by patients who have an appointment for an initial evaluation. This IS NOT a general survey and your data will only be reviewed during a face-to-face interview and physical examination. You will need to fill it out, print it and submit the information then bring the hard copy to the office for your initial evaluation. You may need to contact your doctor for the specific information.
AA Starpoli, MD 55 Montgomery Street Poughkeepsie, NY 12601 1-845-471-1354
AA Starpoli, MD 80 5th Avenue - Suite 1605 New York, NY 10011 1-212-673-2721
© 2013 AA Starpoli, MD | This site is for informational purposes only. Always consult with your doctor before proceeding. Site By: HeyKenneth