So glad you’ll be in to see us. Request an appointment with the form below or call us at (877) 260-0352. We look forward to seeing you! Patient Contact InformationName(Required) First Last Date Of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required) Male Female Address(Required) Street Address City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Patient InsuranceInsurance Company(Required)Select insurance companyNo insuranceNot listedAdd laterAdvent Health Health First AdminAetna HMOBlue Cross Blue ShieldBridge Health PlanCignaFlorida Health Care Plans Holly HillMayo Clinic Health SolutionsTricare East (Reserve)Tricare East PrimePolicy ID Number Is the patient the insurance holder Yes No Appointment DetailsHow Did You Hear About Us?(Required)Select sourceProviderSocial MediaGoogle SearchFriends/FamilySeminar/EventTVInsuranceVABillboardPrevious PatientSpouse is PatientReferring Provider Name (If Applicable) Reason For Appointment(Required)If you do not see your appointment type, please give our office a call at (877) 260-0352.Appointment typeHysterosalpingography (HSG)New Patient AppointmentNew Patient TelemedReconsultationSemen AnalysisPreferred Location(Required)LocationAny/First AvailableAlbany, GABrunswick, GADaytona Beach, FLDaytona Beach, FL - SouthGainesville, FLJacksonville, FL - Baptist SouthJacksonville, FL - BaymeadowsMelbourne, FLOcala, FLOrlando, FLTallahassee, FLTampa, FLTampa, FL - NorthTampa, FL - RiverviewThomasville, GAValdosta, GAWinter Garden, FLPreferred Booking Month(Required)LocationAny/First AvailableJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberConsent(Required)    I agree to this website's privacy policy.