Existing Patients

Call us for an appointment, 904-276-5700, or simply fill out and submit the form below and one of our professionals will contact you shortly.

FIELDS MARKED WITH AN ASTERISK (*) ARE REQUIRED.

THIS FORM IS FOR EXISTING PATIENTS. If you’re a new patient click here.






Your Name*

Date of birth*

Telephone*

Email Address*

REASON FOR VISIT*:

Preferred Physician:
Gary C. Bernard, MD
Leiah Walrod, MD – (She works only on Mondays)

Preferred Appointment Dates:
1st Choice:

2nd Choice:

Preferred Appointment Time

Has your insurance changed? YESNO

If YES, please fill out the information below.

Name of Insurance Company

Membership # / Policy #

Group ID #

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