Appointments Required fields are marked with * Welcome! Every request is important to us. Please complete the following form to request an appointment and have a discovery call. A staff member will follow up with you as soon as possible to discuss further You need to decide on 3 things: How quickly do you need an appointment? Are you requesting a Tele-Medicine consultation? Are you interested in Dr. Rahbar’s services as a:Treating Physician, or as a Consulting PhysicianFIRST, which appointment type do you want?Appointment Type: Physician Prompt - $1495Details- We take extra effort to accommodate your appointment as quickly as possible, generally within 1-2 weeks. - $200 non-refundable deposit is required to book the Prompt Appointment.Appointment Type: Physician Standard - $1295Details- Implies that we provide an appointment based on availability. - $200 non-refundable deposit is required to book the Standard Appointment.Appointment Type: Telemedicine (Video or Phone) Consultation - $1495Details- We provide an appointment based on availability. - $200 non-refundable deposit is required to book the TeleMedicine Appointment.What type of appointment are you requesting?Please choose after reviewing above Physician Prompt Physician Standard Telemedicine (Video or Phone) Consultation SECOND, tell us if you like to retain Dr. Rahbar’s services as Consulting or Treating Physician.Understanding Treating Physician vs. Consulting PhysicianTo visit the physician as your Treating Physician, we require enrollment in our Membership Program. As a Treating Physician, the practitioner will provide medical evaluations as well as order diagnostics (lab & imaging), prescribe medications, assist with referrals, and recommend supplements and will be involved in your day-to-day medical supervision. The fee for the membership program is in addition to fees required for medical evaluations, diagnostics, and therapeutics.Membership Program (12 months) | BEST VALUE $1299 Membership Program (6 months) | $899 ELITE Concierge Services | Fee Individually Customized. Please discuss with Dr. Rahbar directly, preferably after your visit.To visit the physician as your Consulting Physician, membership is not required. The practitioner will only conduct a medical evaluation and provide you with recommendations that you may implement through care and supervision of another treating doctor. Patients may request additional follow-up consultations or can request to be enrolled in our Membership Program (Ask for availability)THIRD, Granted we have availability; would you like to be enrolled in our Membership Program?* Yes, I like to be enrolled Yes, I like to be enrolled, but want to wait until after my first appointment. No, I like only to consult with Dr. Rahbar Now, please answer a few more questionsWere you referred by a healthcare provider? Yes No I am a former patient of the practice more than 3 years ago If yes, please specify the name of the practitioner?Please tell us how you heard about us? Google Search or self-search Word of Mouth Patient of practice Yelp Reviews Other sources -please specify below Other sources - please specifyYour name or nickname*Your AgeYour Gender Female Male Other Prefer not to say Do you plan to use insurance for some of our outside services? PPO Medicare Covered California or other government insurance No FOURTH, Set up a Discovery CallOption 1: Schedule Online If you do not see an available spot on the online calendar, please proceed to Option 2. Option 2: Tell us more how best to reach you Option 2: Tell us more how best to reach youBest days of the week to call you:Best times of the day:The discovery call is with a staff member, not the physician. There is no fee for the discovery call. It will help us to mutually understand if our practice is the right fit for both of us. A discovery call is not immediate and requires a designated time. Email* Phone*Reason for your visit or additional comments*Privacy Policy* I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form. DISCLAIMERS: Please use this form for general information purposes only. DO NOT send personal information through this form. Specific patient care issues must be addressed during your appointment. Availability will vary depending on your request. Submitting the form is not a guarantee of making an appointment. Please note that our response time may vary depending upon the number the practice inquiries we receive and our resources available to respond. We appreciate your patience. Never use this form for urgent matters!CAPTCHASignature*Reset signature Signature locked. Reset to sign again NameThis field is for validation purposes and should be left unchanged.
