pfmindy.com

Appointment Request

Appointment TYPE? * Reason for Appointment *

If you have a medical Emergency, call 911; or If you have an urgent medical need, please call the office at 789-9600.

PREFERRED Appointment

Please provide us with your PREFERRED Appointment DAY and TIME. We will do our best to accommodate your request and will notify you with our availability.

Preferred Day of the Week? Specific Date? Appointment TIME? Other

Patient Demographic Information

Please provide the following information as it pertains to the patient. This will help us... 1) Ensure we have the correct patient, 2) Contact you with our availability to meet your request.

Relationship to the Patient * Patient's Name Date of Birth * How do you wish to be contacted? * Phone Number Email Address * Please list any other members of your immediate family we currently see or have seen in the past.

Insurance

Select your Primary Insurance * Other Insurance Company

Premier Family Medicine accepts all commercial insurances. However, we are not "In Network" with all insurance companies. Also we do not necessarily participate in all health plans offered by insurance companies we do contract with.

Please call your insurance company to make sure we are in network with our specific Health Insurance Plan.