Contact Information

Patient First Name *

Patient Last Name *

Patient Date of birth *

Relationship to Patient *

Legal Representative Name

If Other, Please Specify

Phone *

Email *

Please select your physician *

Address

Street Address

City

State

Postal Code

Insurance Information

Insurance Company

Primary Insurance Holder's Name *

Primary Insured Date of Birth *

Insurance Group Number

Insurance ID Number

Insurance Card Photo (Front) (8mb Max)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Insurance Card Photo (Back) (8mb Max)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Additional Information

Medical Release

I authorize the office of Gene Liu MD & Dr. Arthur Wu MD to obtain and review relevant medical information necessary to evaluate my inquiry and coordinate my care. I understand that my information will be handled in accordance with applicable privacy laws, including HIPAA. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

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