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CALL FOR AN APPOINTMENT

631.533.9733

CONTACT US TODAY

info@nygsurgery.com

BOOK APPOINTMENT 

BOOK APPOINTMENT 

logo

CALL FOR AN APPOINTMENT

631.533.9733

CONTACT US TODAY

info@nygsurgery.com

logo

CALL FOR AN APPOINTMENT

631.533.9733

We’re Here for You

Whether you’re seeking answers, scheduling a consultation, or need guidance about treatment options, our team is ready to help. Reach out today — compassionate, expert care begins with a conversation.

CONTACT INFO

631.533.9733

info@nygsurgery.com

1175 Montauk Highway
Bay Shore, NY 11706

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WITH US

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HOURS OF OPERATION

MON – THUR

8AM – 4PM

FRI

8AM – 12PM

Patient Access & Scheduling

Use the options below to contact our team, request an appointment, register as a new patient, or submit a referral. Select the tab that fits what you need, and the corresponding form will appear.

    "*" indicates required fields

    First Name *

    Last Name *

    Phone Number *

    Insurance Plan *

    Treatment Requested *

    What are Your Prominent Symptoms? *

    Is this a 2nd Opinion/Transfer of Care *

      "*" indicates required fields

      First Name *

      Last Name *

      Phone Number *

      Insurance Plan *

      Referring Provider Name *

      Name of Referring Clinic

      Referring Staff's Name

      Staff's Direct Number *

      Staff's Email Address *

      Treatment Requested *

      Reason for Visit *

      Is this a 2nd Opinion/Transfer of Care *

      Patient Details

      Patient First Name *

      Middle Initial

      Patient Last Name *

      Patient Primary Phone

      Date of Birth

      Additional Documents (Optional)

      Document Upload

      To streamline the referral process, please upload the following documents for the patient you are referring.

      • Face Sheet / Insurance Card

      • Last Chart Note

      • Any Recent imaging or Pathology

      • Any Recent Labs

        "*" indicates required fields

        Patient's Name *

        Email *

        Date of Birth *

        Age *

        Sex *

        Current Address *

        City *

        State *

        ZIP Code *

        Home Phone Number *

        Cell Phone Number

        Employer Name & Address

        Employer Phone Number

        Language

        Ethnicity

        Race

        Emergency Contact Name *

        Relationship *

        Address

        Phone Number *

        Who is your referring OB Doctor?

        Who is your Primary Care Doctor?

        INSURANCE INFORMATION

        Primary Insurance *

        Secondary Insurance

        Patient is Subscriber/Policy Holder

        Patient is Subscriber/Policy Holder

        MEDICAL HISTORY

        Past Medical History

        Past Surgical History

        Medications

        Preferred Pharmacy

        Pharmacy Location (City / Address)

        Allergies

        - OBSTETRICAL HISTORY -

        Pregnancies

        Living Children

        Vaginal Births

        C-Sections

        Ectopic Pregnancies

        Miscarriages

        Abortions

        Could you be pregnant?

        - GYNECOLOGICAL HISTORY -

        Last PAP Smear

        History of Abnormal PAP Smear

        Last Mammogram

        Last Menstrual Period

        Date of First Menstrual Cycle

        Personal History of STD

          "*" indicates required fields

          First Name *

          Last Name *

          Phone Number *

          Insurance Plan *

          Treatment Requested *

          Preferred Date of Appointment

          Preferred Time of Appointment

          Diagnosis *

          Date of Diagnosis

          Insurance Plan *

          Referring Physician or Clinic

            "*" indicates required fields

            First Name *

            Last Name *

            Phone Number *

            Date of Birth *

            What Department Would You Like to Contact?

            Email Address *

            Message *

            SURGERY

            RESOURCES

            Visit One of Our Locations

            375 W. Main Street, Suite 2A
            Babylon, NY 11704

            375 E. Main Street, Ste 7
            Bay Shore, NY 11706