Patient Information Form
 
For the convenience of all our patients we have provided the "Patient Information Form" online, so that you may print it at your convenience before coming for an appointment !  
    Click here to print
   
  To make an appointment please fill out the form below or call our office:
 
 
 
 
 
  * - Required Fields  
 
 
First Name *
Last Name *
Address Line1 *
Address Line2
City *
State *
Zip*
Date of Birth *
LIDI Location *
How would you like us to contact you to schedule appointment? *
 
If you would like to be contacted by phone please leave your telephone number, or if you would like to be contacted via email please leave your e-mail.
E-Mail/Phone *
In order to make an appointment online, please leave the following information: Type of exam needed, type of insurance, and the referring doctors name.
Comments *
 
 East Setauket

23 Technology Dr,
East Setauket, NY 11733-4000

Tel: 631-689-7300
Fax: 631-941-4215
(For scripts and authorizations)
Fax: 631-689-7321(For all other)
Email: sgrasso@lidi.com or nanand@lidi.com

 
 Ridge

679 Whiskey Road,
Ridge, NY 11961-1116

Tel: 631-744-0444
Fax: 631-744-6720
Email: npatterson@lidi.com

 
 Riverhead

205 Osborne Ave.,
Riverhead, NY 11901-3021

Tel: 631-727-6025
Fax: 631-727-6044
Email: bmacdonald@lidi.com

 
 Syosset

100 Lafayette Drive,
Syosset, NY 11791-3934

Tel: 516-364-4600
Fax: 516-364-4646
Email: ldavidson@lidi.com

 
 
   
 
     
 
   
   
     
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