Baldwin Park Family Practice, P.A. | Physicals, Minor Surgery, Aesthetics

1040 Woodcock Road, Suite 200 Orlando, Florida 32803
Phone: 407.898.4550 Fax: 407.898.4842

Online Appointment Request Form: (New Patients Only)

Please fill out the required information in this form and submit. We will contact you to confirm your appointment date and time. Our office will contact you if any additional information is needed.

existing Patients:
This form requires a lot of additional information we may currently have on file for you. If you would like to Update Your Personal Data (address, telephone numbers etc.) please CLICK HERE.

For our Existing Patient Appointment Request Form, please CLICK HERE.

PLEASE NOTE: Items with a red asterisk "*" are required fields. Please fill all of them.

Basic Personal Information

Firstname *

Lastname *

Birthdate*

Street address*

City *

State *

ZipCode *

Phone *

E-mail Address: *

Appointment Request Information

NOTE TO NEW PATIENTS:

To succesfully process your insrance claims, we will need to verify that we are in network with your insurance plan.
Please provide the following information:

	Insurance Co. (Medicare, Aetna, United Healthcare, etc.)
	Do you have secondary/supplimentary insurance?	Yes No
	If you currently do not have insurance, we will still be able to treat you. Please indicate by checking the box below. We will be happy to answer your questions once we establish contact with you.
	I do not currently have health insurance/coverage

Request Date of Visit *

Reason for Visit *

Preferred Day/Time *

	Morning Schedule		Afternoon Schedule
Monday (8AM-12:30PM)		Monday (1:30-4:30PM)
Tuesday (8AM-12:30PM)		Tuesday (1:30-5PM)
Wednesday (8AM-12:30PM)		Wednesday (1:30-4:30PM)
Thursday (8AM-12:30PM)		Thursday (1:30-5PM)
Friday (7:15AM-12Noon)		--- closed ---

Do you have special needs?
(ADA/Handicap Access Etc.)

Yes

Please specify:

Optional Information

How did you learn about us?