Request Appointment

Please note that this form is for requesting appointments only. Availability will vary and someone from our office will call you to confirm your appointment request.
Please do not submit any Protected Health Information.

Location(*)
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Date you would prefer(*)
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Date you would prefer(*)
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Full Name(*)
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Email(*)
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Phone(*)
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How did you hear about us?




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Referred by Doctor?
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Referred by?
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Referred by other?
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Describe nature of appointment(*)

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Please arrive early so that we can complete your initial paperwork. Also, please bring the following:

  • Patient's insurance card
  • List of current prescriptions and/or over-the-counter medication, including dose and frequency
  • Information about patient's medical and surgical history
  • Recent test results, x-rays, or relevant records

Insurance and Payment Information
You are responsible for co-payments or charges that are not covered by your insurance at the time of your visit. If you have questions regarding billing or which insurance plans we accept, please call our office. Questions regarding insurance coverage and benefits should be directed to your employer or insurance company.

Pace Office

3754 US Hwy 90, Suite 230
Pace, FL 32571
P: (850) 299-4345
F: (850) 299-4375

Directions

Jay Office

14122 Alabama Street
Jay, FL 32565
P: (850) 299-4345
F: (850) 299-4375

Directions
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