Questions? Comments? Contact us below and we will be back in touch within 24 hours

ONLY if you have not yet made an appointment with our office - Please complete the online Intake Questionnaire below expedite your intake process. If an appointment has been made please complete appropriate New Patient forms to the right.

Online Intake:

Patient name:
Email:
Address
City:
Zip:
Home phone:
Work phone:
Date of birth:
Social Security # (Optional):
Referring doctor:
Primary care doctor:
Date on prescription:
Reason for referral (Diagnosis):
Have you ever been a patient?:
Preferred day/time for appt:
Billing information:	Select Private Insurance Workers Comp No Fault
Private Insurance Information	Please complete even if Worker's Comp is selected
Primary ID #:
Primary Policy holder name:
Primary Policy holder date of birth:
	Yes No
*Medicare Patients*
Home health care this year?:
Secondary ID #:
Secondary Policy holder name:
Secondary Policy holder date of birth:
Workers Comp Information:	Please complete all information
Compensation carrier:
Claim #:
Date of injury:
Adjusters name:
Adjusters phone:
Employer at time of inquiry:
Employer's phone number:
No Fault Information:
Insurance carrier:
Claim #:
Date of accident:
Insurance adjuster name:
Insurance adjuster phone:
Questions / Comments:

Contact Information:

510 Towne Drive
Fayetteville, NY 13066
USA

Phone: (315) 637-4747
Fax: (315) 637-6711
Website: www.mlcpt.com
Email: ptinfo@mlcpt.com