Pomajzl Surgical Waitlist
Patient Name
*
DOB
Phone
*
New or Established?
NP
EP
Medicare/medicaid?
*
Medicare/Medicaid
NOT medicare/medicaid
Prefers first available pool?
First Available Pool
Pediatrics?
PEDS
Scheduled Appointment Date
*
Patient consents to receive text messages from practice solely related to scheduling.
Yes
Comments
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