SIMEDHealth

Appointment Request

Submitted by Anonymous on Mon, 2015-06-01 14:42

Full Name *

i.e. John Smith

Email: *

i.e. john.smith@mydomain.com

Phone: *

i.e. 352-123-4567

DOB: *

Date of Birth (MM/DD/YYYY)

Insurance:

SIMEDHealth Location: *

Select your SIMEDHealth location.

Speciality *

Choose your physician specialty.

I would like an appointment for first available time.

First Available Time

Additional Notes:

Please provide any request you might have here (i.e name of the provider you would like to see)

HIPAA and PHI Disclaimer

I understand that by submitting my request I may be providing Personal Health Information (PHI) to SIMEDHealth and that this PHI may be viewed by employees or staff of SIMEDHealth.

Helpful Tips

You can conveniently request an appointment using our online Appointment Request. Please include all contact information, your date of birth, the SIMEDHealth location where you would like to be seen, and the physician specialty you are requesting.

If you would like to request a specific physician, you must enter his or her name in the "Additional Notes" section of this form.