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
Andrew Win, MD (Apollo Beach) - Appointments available now!
Gisela Vargas, MD (Brandon) - Appointments available now!
Vanelis Martin, APRN-C (Brandon) - Appointments available now!
Michael Pappas, APRN-C (Apollo Beach) - Appointments available now!
Jason Stibich, MD (Apollo Beach)
Olan Halim, MD (Apollo Beach)
Sarah Mastro, APRN-C (Apollo Beach)
Joe Braden, PA-C (Apollo Beach)
Mack Knowles, PA-C (Brandon)
Paula Proch, PA-C (Brandon) - Established patients only.
Natassa Quinn, DO (Brandon) - Established patients only.
Kristine Rednour, PA-C (Apollo Beach) - Established patients only.
What is the main reason for your appointment?
*
Sick Visit (respiratory, colds, minor injuries, bumps & bruises, joints, etc.)
Chronic Condition Management Visit (diabetes, COPD, CHF, etc.)
Annual Wellness or Preventive Medicine Visit
Lab Review or Pharmacy Refill Visit
Post Hospital or ER Visit
Other
When would you like your appointment?
*
As soon as possible (today if 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
Should be Empty: