SELF REFERRAL FORM

After this form has been submitted, you will be contacted by our office with an appointment date and time.

Today's Date:(Please enter date format as: mm/dd/yyyy)

* required

Who is your Primary Care Physician?:

Reason for visit, please check one:

Diabetes Thyroid Osteoporosis Pituitary Other* required

Last Name:

* required

First Name:

* required

M.I.:

Date of Birth:(Please enter date format as: mm/dd/yyyy)

* required

Address:

Zip Code:

E-mail Address:

* required

Home Phone:(Please enter phone number format as: xxx-xxx-xxxx)

* required

Work Phone:(Please enter phone number format as: xxx-xxx-xxxx)

Cell:(Please enter phone number format as: xxx-xxx-xxxx)

Primary Insurance:

Do you have medical insurance?:(If yes, please enter the Insurance Provider's name and Policy/ID Number.)

Yes No* required

Policy Number:

Gender:

Female Male* required

Race or Nationality:

verification(Please enter the characters listed below)

* required

Our office will contact you regarding appointment.

Office hours & Contact info.

Mon. - Fri., 8:00AM to 5:00PM
1705 S. Adams Street
Tallahassee, FL 32301
Office No.: (850) 224-7154
Email: patient@thyroidcenter.com

Patient Portal

AFTER HOURS CONTACT INFORMATION

You may contact our office number 24 hours a day. After hours, please call the main number and wait for instructions for non-emergency calls. If you have a life threatening medical emergency, call 911.

For medical questions and problems that cannot wait until the next business day, please listen to the message in its entirety for call back instructions. Weekend calls are forwarded to the on call physician.

Please Call Us

If your diabetes control has deteriorated suddenly such that frequent high or low blood sugar is a problem.