New Patient Request An Appointment - Renton

New Patient Online Request for Renton Clinic Visit

Patient Name*

First Name

Last Name

Date of Birth

Email Address*

Cell Phone*

Phone number format: 410-382-8070

Renton Provider*

Any Renton Provider Aaron Butler, MD Mychael Lagbas, MD

Choose your provider. More than one can be requested.

Date of Injury

Referral Source (Optional)

Web Fax/Mail Phone

Clinic Response

Document here how we reached patient

Accepted Insurance

We only accept insurance from car accidents and work related injuries at our Renton clinic.

Other Insurance

Specific plan network will be verified with patient during the time of scheduling.

Referring Care Provider

Description of Injury

Please provide a brief description of your injury.

Our staff or providers should contact you within 2 business days.

Call our clinic at 425-800-9757 if this is not the case and let us know of any problems.