Skip to content
+1 (929) 370-1248
Fax: 909-323-4151
303 5th Avenue Suite 2009, NY, NY, 10016
[email protected]
Home
About Us
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Menu
Home
About Us
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Phone:
+1 (929) 370-1248
Book Now
+1 (929) 370-1248
[email protected]
909-323-4151
Home
About Us
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Menu
Home
About Us
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Book now
+1 (929) 370-1248
303 5th Avenue Suite 2009, NY, NY, 10016
[email protected]
Fax:909-323-4151
Book now
Jonathan Tamaiev MD
Jonathan Tamaiev MD P.L.L.C
+1 (929) 370-1248
Credit Card Information
Card Type
MasterCard
VISA
Discover
AMEX
Other
Cardholder Name
Card Number
CVV
Expiration Date (mm/yy)
MM slash DD slash YYYY
Cardholder ZIP Code
I,
Authorize (enter name below) to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.
Customer Signature
Date
MM slash DD slash YYYY
