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Schedule an Appointment
This form is for requesting appointments only. A staff member will call within 24 hours (regular business hours) to coordinate your appointment. 

This form will not reviewed by clinical staff. Please do not include or request any medical information or advice. 

It is possible that unsecure (unencrypted) email could be intercepted and read by third parties. For this reason, Southwest Medical Group asks that you do not send any personal and/or confidential information, such as, without limitation, social security numbers, through links on this website. We assume no responsibility or liability for interception of personal and/or confidential information that you send in an unsecure (unencrypted) email message.
Family Physicians Group Appointment Request Form

* Indicates required information
PATIENT INFO __________________________________________________________ 
First Name * 
Middle * 
Last Name * 
Date of Birth (mm/dd/yyyy) *    (mm/dd/yyyy)
 
BILLING INFO __________________________________________________________ 
First Name * 
Middle * 
Last Name * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Daytime Telephone * 
Your daytime telephone number is your (please select one): * 

If Other, please specify:
Home Telephone (Please enter your home telephone number here if it is different from your Daytime Telephone number above) 
 
APPOINTMENT INFO __________________________________________________________ 
Appointment Dates and Times: Please list three preferences                                                 
1st choice 
 * 
2nd Choice 
 * 
3rd Choice 
 * 
Reason for Appointment:
(Example: Annual exam; sore throat; follow up the previous appointment, etc.) 
What is a secure number or email address where we can reach you? * 
If email address, please confirm your email address 
Your secure telephone number/email is your (please select one): * 

If Other, please specify:
Best time to call you: * 
 
 
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