76 Boniface Dr. Ste 1, Pine Bush, NY 12566

Tel: 845-545-6212

Patient Portal Log In

Screen Shot 2019-04-24 at 8.50.33 PM.png

WeCARE

M e d i c a l O f f i c e

HOME
FEES
SERVICES
AREAS OF PRACTICE
ABOUT US
FAQ
APPOINTMENTS
More

Use tab to navigate through the menu items.

New Patient Form

Welcome To WeCARE Medical Office

PATIENT INFORMATION:

Today's Date

First Name

Last Name

Email

Street Address

Middle Name

Date of Birth

Sex

Phone

City

State

Zip Code

EMERGENCY CONTACT INFORMATION:

Name

Street Address

State

Zip Code

Relationship

City

Phone

Email

INSURANCE INFORMATION:

Primary Insurance Carrier

Membership No.

Please upload a scanned image of your insurance card and government ID by clicking on the link below.

Upload File

Upload supported file (Max 15MB)

DR ERICKA M VALENZUELA MEDICAL OFFICE, PLLC