Shafa Medical Clinic Midtown Internal Medicine
Shafa Medical Clinic                                                                                                       Midtown Internal Medicine
Complete New Packet Packet (.pdf)
New+Patient+Complete+Forms+2013
New+Patient+Complete+Forms+2013.pdf
Adobe Acrobat document [2.4 MB]

Patient Portal 

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.

Download: Complete New Packet Packet (.pdf) 

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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)

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Frequently Asked Questions 

I'm a new patient, can I have a physical or papsmear done on my first visit? 

Shafa Medical Clinic's office policy is that the first visit with all patients is considered a "new patient" appointment, where their entire history is taken to identify if certain exams and procedures need to be done. Patients are welcome to schedule a preventative visit after this appointment has been completed. Please note that we do not allow new patient appointments and preventative appointments to be on the same day.

I have multiple medical issues that I need addressed, why do I need to make more than one appointment? 

It is easier to make sure each problem is address appropriately and in depth one by one. If a patient comes in with multiple medical complaints, each problem is not going to be addressed to the degree it needs to be in the time frame of your appointment. We ask patients to make problem specific appointments to ensure they get the best care possible by Dr. Modesta-Keyhani. How often have you heard of a patient coming in and stating the doctor seemed rushed or didn't address everything? We want our patients to have the best care, and addressing problems as they come up and on a schedule if chronic allows a productive appointment with the doctor.

I need to see a specialist and they are wanting a referral from your office. What do I do? 

Our office policy is to have patients who's insurance requires a referral authorization come into our office to discuss and go over their referrals with the referral coordinator before we send over the referral authorizations. This ensures that your primary care provider has on file which specialists you are seeing, able to help monitor your health by making sure you are seeing the specialists you need and help you find all of the specialists you need to see, and to make sure your specialist office visits will be authorized - so you don't risk an out of pocket cost with the specialist.

Some specialists may see you before you have seen our referral coordinator and an authorization has been completed. We still require patients to come into the office to see the referral coordinator before we can submit the authorization.

Medical Records Request

Medical Record Request Form
Medical Record Request
Medical record release form.pdf
Adobe Acrobat document [335.0 KB]
  • Can I get same day appointments? 
  • I do not have insurance, no longer have insurance, or are under-insured, can I be seen? 
  • What should I bring with me to my appointment? 
  • What insurance plans do you accept? 
  • Can you call in antibiotics or controlled substances like narcotics? 
  • I need a refill, how do I get one? 

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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Shafa Medical Clinic P.C. 202 East Earll Drive Suite 150, Phoenix Arizona 85012 . USA....Phone (602) 248-8258 ....Fax (602) 248-8259