TeleHealth Follow Up Visit

Full Name*
Prefix First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Phone Number*
E-mail*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please Describe Your Condition for Dr. Lonner. How/When did it Start? Do You Have Pain? If So, Where?
Please upload prior operative reports, pertinent physician/specialist visits, x-rays, CTs and MRIs. *In addition to uploading your images/reports, also kindly mail any images (Xrays, CT, MRI) to 5 East 98th Street, 4th floor New York, NY 10029. Please make sure all CDs being sent are in DICOM compatible format.
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Product Price*
- Tele-Health Follow Up Fee - $100.00
* Tele-Health Follow Up will be provided within 2 weeks of receiving payment

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