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Welcome to Pulmonary Medicine of Dayton, Inc. We look forward to serving you. Kindly fill out - page 1 / 8





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Felipe A. Rubio, MD, FACP, FCCP Hemant M. Shah, MD, FACP, FCCP Mariano M. Iberico, MD, FCCP Salman S. Razi, MD Median Ali, MD Ivo C. Seni, MD Patrick U. Mezu, MD Edgar R. Santillan, MD Keren Ray, DO Keren Ray, DO Jose U. Torres, DO Gnanam Thambipillai, MD Michele Evanson, DO Anne Reddington, DO

Welcome to Pulmonary Medicine of Dayton, Inc. We look forward to serving you. Kindly fill out the enclosed paperwork and bring it with you to your appointment.

  • 1.

    Please give as much detail as possible on the information sheets.

  • 2.

    Please have your family physician give you copies of any testing that you have had that

relate to your pulmonary problems. (Your doctor can also fax these to us at 937-439- 3786.)

  • 3.

    You must bring your insurance card or cards with you. Also, if your insurance requires a referral, you must have it faxed to our office before your appointment.

  • 4.

    Your co-payment will be due at the time of service. We accept cash, personal checks, MasterCard and Visa.

  • 5.

    You MUST bring your chest X-ray and/or CAT scan with you to your appointment. These cannot be faxed. A current X-ray (done within the last 12 months) and an older one (if available) for comparison. These can be actual films or on a CD; either format is acceptable.

Please call at least 24 hours in advance to cancel any appointment. You may be charged a $20.00 fee for a no call/no show office visit. This courtesy will allow another patient the opportunity to be seen sooner. Our main office: Our satellite office:

Kettering Medical Center Physicians’ Office Building 3533 Southern Blvd, Ste 5800 Kettering, OH 45429 Please call us if you have any questions regarding your appointment (937) 439-3600. We look forward to meeting you! Interstate Executive Center 6728 Loop RD, Suite 101 (building 5) Centerville, OH 45459


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