Patient Medical Request
If you need immediate medical attention please dial 911 or go to your nearest emergency room. Please fill out the details and you will be contacted within 3 hours for non-emergencies and 60 minutes for a medical emergency.
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I acknowledge that this request may be subject to $50 After-Hours consultative fee for non-pregnant patients and is not a covered benefit of my insurance.
What is your first and last name?
Please select your Provider:
Dr. Ruth Cousineau
Dr. Robert Katz
Dr. Jay Goldberg
Dr. Suzanne Gilberg-Lenz
Dr. David Finke
Dr. Naomi Suriel
Dr. Lia Labrant
Kristina Hagopian, NP
Enter Your Date Of Birth
For the fastest response you agree to receive a message from the on call Provider to this number. Number forwarding and Google voice are not secure and will not work.
Enter Your Mobile Phone Number
If you need a call back from the on-call physician within 60 minutes select Yes. By selecting No, please allow up to 3 hours for a response between the hours of 9 AM and 9 PM. Non-urgent messages received after 9 PM will be returned the next day.
Is this a true medical emergency?
Are you pregnant or currently trying?
Please Enter Your Message for the Provider On Call
Pharmacy Phone Number
If you will be needing a prescription or requesting a refill please enter your pharmacy phone number, closing time and allergies before submitting this request.
I Confirm the Pharmacy is Open
Please Report Any Medicine Allergies:
No Medicine Allergies
Non-Steroidal Anti-Inflammatory Medications (Ibuprofen, Advil, Motrin, Aleve)