SIMEDHealth

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). Please leave information about appointment request only. If you have information to send to your Doctor or your Care Team, please utilize our PATIENT PORTAL, or contact your Doctor’s office by phone. This information goes to our scheduling department and NOT to your Care team.

Language:

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.

Appointment Request