Tel: 516-326-0707   
Fax: 516-326-1101   
E-mail: info@lungmd.com   
3003 New Hyde Park Rd., Suite 303   
New Hyde Park, New York 11042    
HomePracticeDirectionsPre-RegistrationPrescriptionsPatient Requests
 
 
Related Links
Practice

Physicians and Staff
Sleep Disorders
Office Hours
Acceptable Insurance
 

 

 

  
   
 
     
First Name:
 
 
Last Name:
 
DOB:
 
 
Phone 1 :
 
E-Mail :
 
 
Phone 2 :
 
Doctor's Name:
 
 

Date of  
Appointment:

 
Reffered To:
 
Doctor's ID#:
 
 
Doctor's Phone#:
 
 
Doctor's Address::
 
 

Doctor's Fax #:

 
Reason for Referral:  
Dx Code: (HIP and Vytra Only)   Can obtain from physicians office where appointment will be scheduled)
     
   
     
 
 
 

 

  
 
 
 
site designed & developed by: Digital Vision Productions