New Patients

If you are a new patient to Pointe Medical Services, please call us at 904-276-5700 or you can fill out the information below and one of our professional staff will contact you shortly.

FIELDS MARKED WITH AN ASTERISK (*) ARE REQUIRED. 

THIS FORM IS FOR NEW PATIENTS. If you’re an existing patient click here.






PERSONAL INFORMATION:

Your Name*

Gender*

Address (No P.O. Boxes)*

City*

State*

Zip*

Cell Phone* (We use this to text you an appt. reminder)

Email Address*

Date of Birth*

INSURANCE INFORMATION:

Name of Insurance Company*

Membership # / Policy #*

Group ID #*

REASON FOR VISIT:
Primary Care
Hormone Therapy
General Evaluation
Other – Please explain in the Comments

Preferred Appointment Dates:
1st Choice:

2nd Choice:

Preferred Appointment Time

How did you hear about us?*

Comments