Baptist Health of Northeast Florida - Submit a Primary Care Appointment - Form
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e-baptisthealth.com
Request a Primary Care Appointment
Collins Road, Fleming Island, Mandarin South, Mandarin West and University offices

Scheduling an appointment with your primary care physician is now easier than ever, thanks to e-baptisthealth.com. Complete all of the fields below and select the "Go" box. Someone from the doctor's office will reply and confirm your appointment time within three business days. If you have problems submitting this form, please contact our Webmaster .

Please note: This service is only for NON-emergency appointments. If you have a medical emergency, please call 911.

By submitting your request via this Web page, you are authorizing us to confirm the appointment using the e-mail address you provide below.


New Patient: yes no

Last Name:

First Name:      Initial: (optional)

Date of Birth: Press to popup a calendar      Social Security Number:

Home Phone: () -      Work Phone: () - (optional)

E-mail Address:

Insurance Company:

         Or enter one here if yours is not on the list:

Physician/Provider Requested:

Preferred Date #1: Press to popup a calendar at
Preferred Date #2: Press to popup a calendar at
Preferred Date #3: Press to popup a calendar at

Reason for Appointment:



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