Medical Appointment Request

> Appointment Request ( Medical )

Medical Appointment Request Form

First Name*

Last Name*

Email*

Cell Phone*

Tel. Home

Address*

City*

ZIP Code*

Date of Birth*

Gender*

Male

Female

Ethnicity*

Hispanic

Non-Hispanic

Race*

Are you new patient?*

Do you presently have health insurance*

Yes

No

Reason for Visit*

Appointment Type*

Tele Health

Referral Source*

ORMC

Advent Health

Healthlink

Christian Sharing

Patient in the practice

Word of mouth

Bueno Pharmacy

Other

Remarks

– Urgency? This appointment is urgent. Add me to the waiting list. If available, I can come within 24 hours notice.

Yes

No

–*

By submitting the request, I affirm that I don't have any type of insurance and my last 30 days gross household income is less than 200% below the federal poverty line.

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