Boundary Wellness Center - Patient Intake Form

Schedule an appointment by calling us at 516-694-1590 or simply fill out the form below and click ‘Submit’.

If you are a new patient and would like to prepare for your appointment in advance, you can download our Patient Intake Form and bring it with you to your first visit.

Boundary Wellness Center
Please complete this form and we will respond to you
within 24 business hours.  We look forward to speaking with you.
First Name:
Last Name:
Sex: MaleFemale
Social Security#:
Date of Birth:
Address Street:
Zip Code: (5 digits)
Insurance Name:
Insurance ID#:
Who is the insurance carrier:
Insurance carrier SS#:
Best place to reach you: Home WorkCell
Best time to reach you:
Home Phone:
Work Phone:
Cell Phone:
How did you hear about our office?: