General Medicine Clinic: Dr C Osuji

Available Forms

Agreement to Receive Chronic Care Management Services for Medicare patients Appointment request Asthma Control Test Balance self-test (please fill prior to every visit and press send) por favor, llene antes de cada visita y pulse enviar Checklist for Medicare Annual Wellness Visit Controlled med contract Cough/cold/sinus infection COVID-19 Patient Screening Questionnaire COVID-19 poner en pantalla COVID-19 QUESTIONNAIRE COVID-19 SCREENER Depresión Employment form Espanol vacuna COVID-19 Flu History - Please fill out prior to your visit. For 2nd visit and after, please update New patient form New pt Spanish OB/GYN ANNUAL INTAKE Patient Health Questionnaire - Depression Screening Patient/Health Care Provider E-mail/Texting Consent Reason for your next office visit Record request Referral request (requests are processed in 5 working business days) If urgent request needed, please call office to pick up btw 12 noon at 4 pm Refill request Spanish New Patient Telehealth Consent Telephone or message Consultation (for Clinic patients only) Video conference for patients VITALS

Telephone or message Consultation (for Clinic patients only)

First Name *

Last Name *

Date of Birth *

Reason for Consultation *

For refills of controlled medications, an office visit is required

Has payment been made? *

To make payment, please call office at 2818597100. You can fill the payment form or request a payment form by emailing us at genmedclinic@myupdox.com. You will be contacted within 4 hours. <br/>Can?t telephone? Visit https://spruce.care/yortktown-crossing and send a message and that can include pictures of rash.

Medicare, Medicaid, BLUE CROSS BLUE SHIELD, AETNA, CIGNA, Humana, Unted Health Care MEMBER ID

Contact phone (if different from number on profile)

Please go to the link to pay

https://checkout.square.site/pay/8a685bcc-5fa1-4731-a292-f1398a82ee7a?t=1595538689.027931

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