Healthcare Digital Forms by

Submit your case - Dr. Ares, MD

Use this form to refer yourself or another patient for evaluation in our office.

Please provide as much information as possible to better evaluate your referral.

Data encrypted through HITRUST CSF certified technology for HIPAA Compliance

Patient Information

First Name *

Last Name *

Gender Assigned At Birth

- select -

Date of birth *

City *

State *

Country

Enter your country

Postal Code

Email *

Phone *

Alternate Phone *

Work Phone

Other Phone

Name of your insurance

Diagnosis

- select -

Specify other diagnosis:

Diagnosis Date

Are you currently under treatment for this condition?

- Select -

If yes, specify current treatment:

Upload imagery and notes
Please upload any images (CT/MRI scans, X-rays, test results), individual pictures (JPEG, PNG), or camera/phone photos that will help us evaluate your condition. In addition, a description of imaging findings or a radiologist’s report (PDF) may be submitted here.

Upload Scans

PDF, PNG, JPEG or JPG ( max 20 Files )

Reason for referral *

Specify other reason

We believe an in-person consultation is the best way to evaluate your symptoms and provide the best possible recommendations. In many cases, however, virtual consultations (via video conferencing) can be accommodated. Please indicate your preference below *

If you are a referring provider, please write your name and preferred method of contact (phone, email, or other)

If you would like to leave a further message, please type it here

UTM Source

UTM Medium

UTM Campaign

UTM Content

UTM Term

UTM Device

GCLID

GBRAID

WBRAID

I consent to receive text and/or email messages. Message frequency may vary, and msg/data rates may apply. Messages may include marketing, patient care, or conversational content.