MedicsPremier - Patient Portal

New Patient

Woodbridge Internal Medical Associates
1000 Route 9 North
Suite 302
Woodbridge, NJ 07095

Appointment Selection

Please note that your booking request is preliminary and is subject to office approval. Once your appointment has been approved you'll receive a confirmation e-mail. You may book up to 60 days in advance.

Place of Service: *

Provider/Doctor: *

Appointment Type: *

Authorization/Certification Number:

Availability for 04/19/2024

Open appointment times within 4 hours of the current time are not shown. Please call the office if you require immediate availability.

Please make a selection above.

Fields marked with a (*) are required.

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: *

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.

Fields marked with a (*) are required.

Credit Card Information

Credit Card Information

We would like your credit card information prior to submission of your registration request.

Credit Card Number:

Card Verification Value:

Expiration Date (MM/YYYY):

Pre-Booking Summary

$pat_name is scheduling an appointment for $date at $time with $res_name for $appt_type.

This appointment request is contingent upon approval by the practice. You'll receive an e-mail confirmation once your information has been validated and your appointment request approved. If you have any questions in the meantime, please don't hesitate to contact the office at (732) 634-0036.

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.

Do you have any special requests that we should be aware of? For example, require a wheelchair, service animal, or other accommodations.

Please sign below: *

Please review the information above prior to submitting this form.