Call Us: 904-621-8042

New Patient Appointment

If you are a new patient to Pointe Medical Services, please call us at 904-621-8041 or you can fill out the information below and one of our professional staff will contact you shortly.

FIELDS MARKED WITH AN ASTERISK (*) ARE REQUIRED. 

THIS FORM IS FOR NEW PATIENTS

PERSONAL INFORMATION:

Your Name*

Address (No P.O. Boxes)*

City*

State*

Zip*

Telephone*

Email Address*

Date of Birth*


INSURANCE INFORMATION:

Name of Insurance Company*

Membership # / Policy #*

Group ID #*

Name of Insured Other Than Patient*

Subscriber Date of Birth*

Relationship to the Patient*


REASON FOR VISIT:
New Patient
Follow-Up Visit
Hormone Evaluation


PREFERRED PHYSICIAN:
1st Choice:
Gary C. Bernard, MD - (Orange Park location)
Michael Kight, PA - (Orange Park location)
Kimberly M. Hunt, ARNP - (Baymeadows location)


2nd Choice:
Gary C. Bernard, MD - (Orange Park location)
Michael Kight, PA - (Orange Park location)
Kimberly M. Hunt, ARNP - (Baymeadows location)


Preferred Appointment Date

Preferred Appointment Time

How did you hear about us?*

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