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Submit your case - Dr. Ares, MD

Use this form to refer yourself or another patient for evaluation in our office. 

Please provide as much information as possible to better evaluate your referral.

Data encrypted through HITRUST CSF certified technology for HIPAA Compliance
 
Patient information
 

First name*:


 

Last name*:


 

Gender assigned at birth:


 

Date of birth*:


 

City*:


 

State*:


 

Zip code:


 

Country:


 

Email*:


 

Home phone*:


 

Alternate phone*:


 

Work phone:


 

Other phone:


 

Name of your insurance:


 

Diagnosis*:

 

Specify other diagnosis:

  

Diagnosis date:


 

Are you currently under treatment for this condition?:


 

If yes, specify current treatment:

Upload imagery and notes
 
Please upload any images (CT/MRI scans, X-rays, test results), individual pictures (JPEG, PNG), or camera/phone photos that will help us evaluate your condition. In addition, a description of imaging findings or a radiologist’s report (PDF) may be submitted here. 

The total combined max upload size is 30MB. Your files will be uploaded after clicking submit form. Please do not exit this window until you see a confirmation. If you are having difficulty uploading images to this form, please contact our office. We will be happy to find another way to obtain your images.
 
 
 
 

Reason for referral*:

Specify other reason:

   

We believe an in-person consultation is the best way to evaluate your symptoms and provide the best possible recommendations. In many cases, however, virtual consultations (via video conferencing) can be accommodated. Please indicate your preference below*:​​​​​​


If you are a referring provider, please write your name and preferred method of contact (phone, email, or other):



If you would like to leave a further message, please type it here:

  

 
 

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