* Required

Patient Information

Please note: We cannot process emergency requests through this form. If you are experiencing a medical emergency, please call 9-1-1.

To schedule an appointment by phone, please call the medical office directly and speak with an associate:


Nezhat Medical Center: (404) 255.8778 (9am - 5:30pm EST Mon-Thu) (9am - 3:30pm Friday) (Closed Saturday and Sunday)

 

Insurance Coverage for Nezhat Medical Center:

We appreciate you choosing us for your health care needs. One of our representatives is happy to answer any questions regarding insurance coverage and payment with Nezhat Medical Center. For insurance accepted at Nezhat Medical Center, please contact our office directly at (404) 255.8778 or E-mail Mary Ann Bumgardner at mbumgardner@nezhat.com.

The person who will be seeing the physician.
* Indicates all required fields in order to submit this form.












(Tip: Use Address Line 2 if more than 25 characters required in Address Line 1)









Home Phone
Work Phone
Cell Phone


Patient information


Yes
No

Yes
No



Yes
No



Requester's information








Yes
No


Captcha Image