MedicsPremier - Patient Portal

New Patient

Welcome to the Patient Portal for Foot Associates of New York.
3616 Henry Hudson Parkway
Bronx, NY 104631505

Patient Profile

Please type in your information below.

First Name: *

Middle Name:

Last Name: *

Date of Birth: *

Sex: *

Home Phone Number: *

Mobile Phone Number:

Street Address: *

Apt/Suite/Other:

City: *

State: *

Zip Code: *

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Fields marked with a (*) are required.

Online Account

Please select a username for your online patient portal account below.

Username: *

E-Mail: *

Password: *

Confirm Password: *

Passwords should be a minimum of eight (8) characters.

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Insurance Information

Please type in your primary insurance information below.

Insurance Company:

Policy Number:

Group ID:

Related to an accident or worker's comp. claim?

Date of Incident:

Case Number:

Claims Number:

Comments:

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Pre-Booking Summary

This is a preliminary new patient registration only. No appointment will be created at this time until your information is verified by our practice. If you have any questions, please contact us directly by calling 718-548-5757 EXT 102.

By clicking on the 'Finish/Request Appointment' button I've read and understand the Privacy Policy and Terms of Service documents governing the use of this site.
Please sign below: *

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Please review the information above prior to submitting this form.

Request/Registration Confirmation

Thank you $pat_name for registering as a new patient at $practice_name! Your request has been successfully received and will be processed as soon as possible. We may reach out to you if we have any questions or require further details from you.

Please note that this is NOT a new appointment request and you will be contacted once you are able to request a visit via the website.

Your portal username is $user_name. Once your registration information has been approved, you'll be able to login to your online patient portal account.

Reminder: $appt_reminder