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  • 210 E 47th Street Suite 1A
  •  212-308-4894
  • 646-585-9194 (Fax)
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  • Home
  • About Us
    • About Dr. Chi Shum
    • Insurance Networks
    • Our Staff
    • Clinic Photo Gallery
  • Patient Services
    • Onsite Services
    • Offsite Services
    • Patient Forms
    • Patient Education
    • Referrals
  • Doctor’s Blog
  • Contact Us
    • Prescription Refill Request
    • Feedback
    • Contact Us
  • Submit Payment

 

patient forms

Adult ADHD Self-Report

Hamilton Anxiety Rating Scale

Mood Disorder Questionnaire (MDQ)

Cancer Risk Assessment

Depression Screener

Vision Test Report

Epworth Sleepiness Scale

Flu Vaccine Consent

Healthcare Proxy

HIV Consent Form

Low dose CT lung cancer screening

Low-Dose CT Lung Cancer Screening

Medical Record Release

MTA

Pain Agreement

Patient Demo

Patient History Form

Patient Privacy

Pre Vaccination Screening Form

Sexual History

Telehealth Consent Form

VNSNY Physician Referral Form

  • 210 E 47th Street Suite 1A
    New York, NY 10017
  • 212-308-4894
  • 646-840-0648
  • 646-585-9194 (Fax)

About Us

  • About Dr. Chi Shum
  • Patient Forms
  • Insurance Details
  • Our Staff
  • Appointment
  • Admin

Quick Links

  • Doctor’s Blog
  • Referrals
  • Submit Payment
  • Contact Us
  • Feedback
  • Prescription Refill Request

Opening Hours

  • Monday: 8.00AM - 4:45PM
  • Tuesday: 8.00AM - 4:45PM
  • Wednesday: 8.00AM - 4:45PM
  • Thursday: 8.00AM - 4:45PM
  • Friday: 8.00AM - 4:45PM
  • Saturday: 8.00AM - 3.00PM
  • Sunday: Closed
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