Angela Azar M.D. PC

Dermatology & primary care

Angela Azar M.D. F.A.A.D.Liliya Besedina M.D. F.A.A.D.Sydney Coscia PA-C.Sariana Almonte PA-C.

New patient intake

Start your visit with clarity.

A few details help our team prepare for your appointment. Save your place as you move through each section.

Confidential medical record

935 Northern Blvd, Suite 106
Great Neck, NY 11021

92-11 Roosevelt Ave, Jackson Heights, NY

New patient intake

Start your visit with clarity.

Complete each section so our team can prepare for your appointment.

Section 01 of 04

Estimated time remaining: 8 minutes

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Patient information

Tell us who you are

Please print clearly in your responses. Use N/A when a question does not apply. Fields marked with an asterisk are required.

Basic details

Your legal name and the best ways to reach you.

First name*

Last name*

Date of birth*

Gender at birth*

Home phone*

Cell phone*

Today's date*

May we leave a detailed message?*

YesNo

Email address*

May Angela Azar M.D. PC send email to this address?*

YesNo

Home & work

Your current contact and employment information.

Home address*

City*

State*

Zip code*

Marital status*

Place of birth*

Occupation*

Employer*

Primary insurance company*

Secondary insurance company (if applicable)

Who referred you to us?*

Primary care physician

Copies of reports and results should be sent to:

Physician's name*

Address*

Phone number*

Fax number*

Pharmacy information

Pharmacy name*

Phone number*

Address*

City*

State*

Emergency contact

Name*

Relationship to patient*

Phone*

A few questions before your visit

These questions help us plan safely for your care.

If you are a female, are you, or is there a chance you may be pregnant?

YesNo

Are you nursing?

YesNo

When was your last menstrual period?

What skin issue will be discussed today?

Past dermatological history

Please answer yes or no for each item.

Melanoma

YesNo

Eczema

YesNo

Squamous cell skin cancer

YesNo

Psoriasis

YesNo

Basal cell skin cancer

YesNo

Other dermatological history

Submission is sent to the practice delivery service.

Angela Azar M.D. PC · Liliya Besedina M.D. F.A.A.D. · Sydney Coscia PA-C. · Sariana Almonte PA-C.935 Northern Blvd, Suite 106, Great Neck, NY 1102192-11 Roosevelt Ave, Jackson Heights, NY