Request an Appointment for a Medical Procedure

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

Procedure Information

(PDF, JPG, GIF or TIFF formats only)
(If different from referring)

Appointment Scheduling

Patient Information

Patient's Address Country*:

Parental Information


Insurance Information

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

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)