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  Review Intake Form

In order to comply with HIPA regulations in regards to patient privacy, a signature is required in order to properly submit the Review Intake Form. You need to download the form in one of its two formats: a 16K Adobe Acrobat PDF, or a 27K Microsoft Word document. Then fill it out, sign it and date it, and mail or fax it to us. If you would like to email a copy of the form to us prior to mailing/faxing it, please put your surname(s) in the SUBJECT of the email message (i.e. subject of email would be "Review Intake Form - Aronson"). Our mailing address is listed below, and our fax number is 212.207.6665.

 

 
 

iph International Pediatric Health Services, PLLC
Dr. Jane Aronson
151 East 62nd Street, Suite 1A
New York, NY 10021
P: 212-207-6666
F: 212-207-6665
E: E-mail us

 

   
   
  This page last updated November 27, 2007 3:45 PM EST