



	Online Appointment

Our Professional Staff

Our Services

Office Hours & Locations

Insurance We Accept

Our Hospital Affiliations

MAKE YOUR APPOINTMENT

Use this feature for non-emergency, non-urgent appointments only.

This feature should be used ONLY for well child visits, physicals, and other visits that can be scheduled several days in advance. Our staff will check for these appointments during regular business hours. If it is an emergency, call your doctor's office and indicate to the answering service that it is an emergency, call 911, or take your child to a hospital ER.

If your child is ill or a new patient to our practice, please call us at one of the numbers below to schedule an appointment by phone.

Park Street: (904) 387-6200
Southside: (904) 997-0023

ONLINE APPOINTMENT FORM

(Missed appointments without 24 hours cancellation will result in $25.00 charge)

*Denotes required field

Child's First Name*

Child's Last Name*

Sex*

Male Female

Date of Birth*

Month Day Year (yy)

Daytime Phone*

Your E-Mail*
(i.e. myaddress @yahoo.com)

Appointment Type*

IMPORTANT: This should not be used for urgent matters. In emergencies, call your doctor's office, call 911 or visit an emergency room.

Physician/Clinician*

Location*

Comments

Appointment Choice 1:
Date:
Time Range:	AM PM
Notes:
Appointment Choice 2:
Date:
Time Range:	AM PM
Notes:
Appointment Choice 3:
Date:
Time Range:	AM PM
Notes:

Are you willing to see another physician/clinician if yours is unavailable?	YES NO

* required information

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