REQUEST AN APPOINTMENT - LifeChoices Medical

Patient Information

First Name*

Last Name*

If patient is a minor, name of Parent/Guardian

Home / Mailing Address

Street Address*

Address Line 2

City*

State*

ZIP Code*

Sex*

Date of Birth*

Optional: To include additional family members, please provide below name(s) and date(s) of birth. 5000 max characters

Where can you be reached during business hours?

Best Phone Number*

Email Address*

Confirmation Email Address*

Insurance Information

Self-Pay or Insured?*

Relationship to Policyholder*

Policy Holder Name*

Policy Holder Date of Birth*

Specific Insurance Plan Name*

Member/Subscriber ID*

Group Number*

Insurance Phone Number*

Insurance Address to Mail Medical Claims*

About Your Appointment

Type of Visit*Primary Care OnlyPrimary Care & GynGyn Only

Detailed Reason for Visit*

Choose Your Top 3 Preferred Dates (Monday-Thursday 8 am – 4 pm; Friday 8 am – 12 pm). Please request dates at least two weeks in the future to ensure we can accommodate. We do maintain an active waiting list for slots that become available earlier.

First Preference*

Second Preference*

Third Preference*

Preferred Time of Day*
MorningMid-DayAfternoonAny

What pharmacy do you use (include phone number)?

What lab do you use?LabcorpQuest

How did you hear about us?

Would you like to receive future communications about LifeChoices Family
Medical’s philanthropic efforts to provide natural, holistic and life affirming medical care in Tampa Bay?Yes, please add my contact information to your ministry database.No, not at this time.

Optional: For additional notes, comments or questions. 5000 max characters

To process your request, we need additional documentation. Please upload a copy of your photo ID. If you have insurance, please upload a copy of the front of your insurance card and a copy of the back of your insurance card. (Please submit a horizontal photo)

Photo ID for both Self Pay and Insured Patients (Please submit a horizontal photo) Max. 5mb max

Front of Insurance Card for only insured patients Max. 5mb max

Back of Insurance Card for only insured patients Max. 5mb max

Only hit the SUBMIT button once. Upon receiving your completed form, your photo ID and the front and back of your insurance card (if applicable), a team member will contact you within the next 2-4 business days

Thank you for completing the form. Our team members will get back to you either by phone or by email.

Please fill all required fields.

Patient Information

Home / Mailing Address

Where can you be reached during business hours?

Insurance Information

About Your Appointment

LifeChoices Family Medical is a Nonprofit in need of your support.