New Patient Form

Step 1 of 9

  • EMPLOYER INFORMATION

  • MM slash DD slash YYYY
  • REFERRED BY - Please tell us who referred you to Dr. Kashyap.

  • POLICY HOLDER / INSURED INFORMATION - Primary Insurance

  • UPLOAD INSURANCE CARD AND DRIVER'S LICENSE

  • Please upload (or fax or email) a copy of the front and back of your Insurance Card and Driver's License:

    1. Scan or use your mobile phone to take photos of the front and back of your Insurance Card, and your Drivers License.
    2. Click the 'Choose File' button below to upload the photos to this form (you may need to email them to yourself first and then save the attachments to your computer before uploading them here).
    3. Or, rather than uploading here, email the photos to our office at info@galleriawomenshealth.comOR fax them to our office 702-476-9202.
  • Drop files here or
    Max. file size: 5 MB, Max. files: 6.
    • PHARMACY OF CHOICE DETAILS