Call Us : 305-279-7275

Make an Appointment

Make An Appointment

  Personal Information

First Name*
Last Name*
Middle Name
Birth Date* (MM-DD-YYYY)
 Male Female
Last Four Digits Of Social Security Number
Best Daytime Phone Number
Email Address*
Reconfirm Email Address*

  Appointment Information

Your appointment is for which of the following. (Check all that apply)*

If you selected 'Other', please specify
What is the Diagnosis?*

Who is the ordering physician?*

Upload a copy or a picture of your doctor's prescription
Please select your location of preference*
Please select your appointment time preference*

  Primary Insurance Information

Insurance Company Name
Policy Number
Group Number
Pre-certification or Benefits Phone Number(s)