Appointment / Call Back Request Form

Please utilize this form to request an appointment with

The Medical Group at South Miami.

Location:

The MD Group @ South Miami

6701 SW 72nd Street Suite 212 Miami, FL 33143

Tel (305) 663-0710 Fax (305) 665-3051

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PLEASE NOTE:

We will contact you within 24 hours with information about your request. If you submit your request on a holiday or Friday afternoon through Sunday, we will respond by the end of the next business day.

Please use this form to contact our Appointments Team

Your Name:

Your Phone:

Your Email:

Your DOB:

Service Type Requested:

Physician:

Request appointment on first available:

Comments:

Please describe how we can help you!

DISCLAIMER INFORMATION

If you do not hear from us within 24 hours please contact us at (305) 663-0710. You acknowledge the risk of sending this information by email and agree not to hold The Medical Group at South Miami liable for any damages you may incur as a result of the transfer or use of this information. The use or transmittal of this form does not create a physician-patient relationship. More information regarding the confidentiality of this request can be found in our Privacy Policy

Appointment Request Privacy Policy

In order for you to request an appointment electronically, you will need to provide confidential medical information. By proceeding through this notice and providing the requested demographic and medical information, you consent to the disclosure of such information to the relevant clinical staff at The Medical Group at South Miami.

The information that you provide will be placed into our electronic database. Your specific information will be accessed and used only for scheduling purposes. Aggregate data (without patient identifiers) may be analyzed at a later date. The information that you provide will not be shared with other organizations, and cookies or other tracers will not be used to collect information or track your computer use. However, you should note that electronic mail and other Internet communications channels may not be secure against interception by non-authorized individuals. If you do not wish to transmit your medical information electronically, you should call the The Medical Group at South Miami at to request an appointment.