Online Presentation Registration

Please fill out the form below with as much information as possible, this will help us expedite the processing of your information.

If you have any questions or concerns regarding the registration form, please contact our office at 631-689-0220.

You will receive the registration information, including the video presentation, within the next 1-2 business days.

Please fill out the form below with as much information as possible, this will help us expedite the processing of your information.

If you have any questions or concerns regarding the registration form, please contact our office at 631-689-0220.


You will receive the registration information, including the video presentation, within the next 1-2 business days.

Contact Information
  • First Name *
  • Last Name *
  • Date of Birth
  • Contact Number *
  • E-Mail Address *
Personal Health Details
  • Reason for your appointment:
  • What is your height? feet Inches
  • What is your weight? lbs
Insurance Information
  • Do you have Health Insurance:  Yes No
  • Insurance Carrier:*