Sending...

Loading
Personal Information Appointment Information Contact information Insurance Information Expectant Mothers
     
First Name :   First Name is required
Middle Name :
Last Name :   Last Name is required
Birth Date :   Date of Birth is required Date of Birth is invalid DOB Error
Last 4 SSN : Last4 SSN Error
Birth Sex :   Birth Sex is required
Legal Sex :   
Address :   Address is required
City :   City is required
State :   State is required
Zip Code :   Zip Code is required
Your appointment is for which of the following. (Check all that apply) * Please select procedure

Select procedure
Please specify other Other procedure is required
Breast Care Options
Please specify other Other procedure is required
Body part   Body part is required
Reason for Exam   Reason for Exam is required
Who is the ordering Physician?    Ordering Physician is required
Preferred Date Invalid Date Online date must be at least 2 days in the future
If you need an appointment within the next 24 hours,
please call the scheduling department directly at 561-955-4700 to expedite your request Preferred Date is Required Preferred date error
Preferred Time   Appointment Time is required Preferred time error
Preferred Location
Location is required Preferred location error
Best Contact Number   Phone Number is required Invalid Format (use: XXX-XXX-XXXX)
Alternative Phone Number   Invalid Format (use: XXX-XXX-XXXX)
Email Address   Email Address is requiredInvalid Email Address
Emergency Contact Information
Emergency contact name   Emergency contact name is required
Emergency phone number   Emergency Phone Number is required Invalid Format (use: XXX-XXX-XXXX)
Emergency contact relationship to patient   Relationship to patient is required
Confirm Email Address   Confirm Email Address is requiredEmails not matching
Please call for self pay rates 7 days a week 7am to 8pm 561-955-5118
Primary Insurance Information
Insurance Company Name   Insurance Name is required
Insurance Company Phone Number –
Located on back of insurance card 		  Insurance Company Phone Number is required Invalid Format (use: XXX-XXX-XXXX)
Policy Number   Policy Number is required
Policy Name of Insured   Insured Policy Name is required
Policy Holder Name   Policy Holder Name is required
Policy Holder Date of Birth   Primary Policy Holder Date of Birth is required
Relationship to Policy Holder :   Relationship to Policy Holder is required
Secondary Insurance Information
Insurance Company Name
Policy Number
Policy Name of Insured   
Policy Holder Name    A potentially dangerous Request.Form value was detected from the client
You can upload your Insurance details here  max 4MB Uploading file
File Size cannot be greater than 4MB File is Required Please click on the upload button
Delivery Information
Delivery information is required
Expected Delivery Date Expected Delivery Date is required
Physician name Physician name is required
Newborn Insurance Information (If different from yours)
Insurance Company Name
Policy Number
Name of Insured
Policy Holder Date of Birth   
Policy Holder Name   
Click YES to receive information via email about our free pre-natal and post-partum classes, support groups, and resources
Please select one
For more information, please visit, baptisthealth.net/gutin.

Sending