Become Our Patient / Review my Case

To initiate the new patient process or to determine whether you are a good candidate for our practice, please complete the following form.

Note: You must complete all fields before you can submit the form. If you prefer to speak with a team member over the phone, please call (212) 988-1444 Monday through Friday, 9:00 am-5:00 pm EST.

    Date of Birth *

    What are your prominent symptoms? *

    Have you had previous endometriosis surgery? *

    How many prior endometriosis surgeries have you had? *

    Do you think you will need surgery? *

    Name of the insurance company *

    This practice does not currently participate in Medicare, Medicaid or Community Plans.

    Insurance Member ID*

    Please let us know what time is best for us to call you.*

    I prefer:

    How did you hear about us?*

    All fields with * are required.