new patient? no problem.

New Patient Form

please fill out the form below

Please contact us directly with any questions or scheduling inquiries you may have.

Full Name

D.O.B

Address

Phone

Date of Injury / Accident

Body Parts of Injury

Did you go to hospital or urgent care?

Yes

If yes, where?

Were any tests done?

Yes

If yes, what kind (e.g., x-rays, CTs, MRIs)?

Attorney Information / Referral Source:

This injury was from:

Work Related Accident

Auto Accident

Other

If work related, who is your employer?

If auto accident, which auto insurance (e.g., Geico, Allstate, State Farm, Liberty Mutual, Nationwide, etc.) does the driver of the vehicle have?

Thank you for the information. We will reach out to you shortly to schedule an appointment. - Q&M

Hours of Operation:
Monday : 9:00AM–5:00PM
Tuesday : 9:00AM – 6:30PM
Wednesday : 9:00AM–5:00PM
Thursday : 9:00AM – 6:30PM
Friday : 9:00AM–5:00PM
Saturday – Sunday: Closed

Phone: (516) 898 – 7676

Email: quan@qmmedicalpllc.com

Address: 91 N Franklin St, Suite #101 Hempstead, NY 11550