Shafa Medical Clinic Amanda Modesta-Keyhani Board Certified in Internal Medicine
Shafa Medical ClinicAmanda Modesta-KeyhaniBoard Certified in Internal Medicine

Medical and Forms

New Patient Packet
New Patient packet - Shafa Medical Clinic
New+Patient+Complete+Forms+2013.pdf
Adobe Acrobat document [2.4 MB]

New Patient Forms: Please download this entire packet to fill out before your appointment. 


Please also bring the following materials for your first appointment: 

 

Picture ID *

Insurance Card *

Copay due* (If you have a percentage% copay, we will bill you after your visit is completed.) 

 

 Medication list (including name, strength, and prescribing doctor)

*These are required for the first appointment. If you do not have them, we will have to reschedule you. 
 

 New patient appointments include taking a full history and a brief physical exam. Please note that we do NOT do preventative services on the first appointment/new patient appointment. Preventative services (ie: annual physicals and papsmears) can be scheduled no sooner than the next day. 

 

 You are responsible for all copays, deductibles, and procedures that your insurance states is patient responsibility. If you have questions about coverage, please contact your insurance company for more information. We do offer cash discounts to those not wishing to use their insurance/without insurance. FAQ's are at the bottom of the page. 

 

 

 

 

Helpful Links and Forms

Below are some helpful links and websites for patients, including printable forms and informational sites. 

Arizona Durable Health Care Power of Attorney - Instructions and Form 
Arizona Life Care Planning (including POA, Living Will, DNR orders) 
MVD Disability Plate/Placard Application 

HIPAA Health Information Privacy Resources 
USDA Choose My Plate (nutrition resources) 
Medline Plus (Rx drug information) 
National Institute of Health (disease and health information)

Top Doc

Make an appointment Today!

Shafa Medical Clinic
202 E Earll Drive
Suite 150
Phoenix, Arizona 85012


Phone: 602-248-8258

Fax 602-248-8259

E-mail: shafamedicalclinic@gmail.com

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