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Request an Appointment for a Medical Procedure

To request an appointment by phone please call (305) 663-8413.

Appointment Scheduling

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Procedure Information

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(If different from referring)

Patient Information

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Patient's Address Country:

Parental Information

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Insurance Information

For an explanation of accepted health plans please visit our list of Insurance providers accepted.
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Medical History






(For example: ear tubes, clips, shunts [programmable or non-programmable], ITB pump, PDA [metal in heart], pacemaker, mediaport, Vagus Nerve Stimulator, braces/dental work)
(Use only numbers and specify in pounds)









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