Appointment Request
In many cases we can get you seen the same day or the next day depending on when you submit your request!
Name
*
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Cell Phone Number
*
Email
example@example.com
General type of Insurance?
Commercial (Through an Employer)
Traditional Medicare
Medicare Advantage Plan
No Insurance - Self Pay
Exchange Plana / Marketplace
Other
What is your specific insurance or payment method? (We don't take Medicaid or any Medicaid HMOs)
*
Private Pay
Medicare
Aetna
Avmed
Cigna
Florida Blue
Humana
UnitedHealthcare
Tricare
Devoted
Oscar
Other
What is your insurance member number?
What is your insurance group number?
If there is a phone number on your insurance card, please list it below.
Have you been seen as a patient in our office before?
*
Yes, I am a current office patient.
No, I have never been there before - New Patient
Which Office and Provider?
*
First Available - Any Office (Brandon or Apollo Beach)
First Available - Brandon Office Only
First Available - Apollo Beach Office Only
Olan Halim, M.D. (Apollo Beach) - Appointments available now!
Shannon Jamerson, APRN-C (Brandon) - Appointments available now!
Joe Braden, PA-C (Apollo Beach)
Dr. Mahin Baha - (Brandon)
Kristine Rednour, PA-C (Apollo Beach)
Dr. Jason Stibich (Apollo Beach)
Dr. Natassa Quinn (Brandon) - Established patients only.
Mack Knowles, PA-C (Brandon)
Paula Proch, PA-C (Brandon) - Established patients only.
Sarah Mastro (Orr), APRN-C (Apollo Beach)
Michael Pappas, APRN-C (Apollo Beach) - Appointment available now!
When would you like your appointment?
*
As soon as possible.
In the next 2 to 3 days.
4 to 7 days.
Sometime in the next month.
Not urgent, just find me an open appointment.
Preferred Times:
*
Early Morning (8AM - 10AM)
Late Morning (10AM - Noon)
Early Afternoon (1PM - 3PM)
Late Afternoon (3PM - 5PM)
Tell us a bit about your appointment request, problem, or need? *
*
Have you been admitted to a hospital or went to the emergency room (ER) in the last 12 months?
*
Yes
No
If so, please summarize where, when, and why you were admitted to a hospital or visited the emergency room.
Submit
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