New Patients

If you are a new patient to Pointe Medical Services, please call us at (904) 276-5700 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. 

PERSONAL INFORMATION:

Your Name*

Address*

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)
 Leiah Walrod, MD – (Orange Park location)
 Keisha Pugh, ARNP – (9A & Baymeadows Rd location)


2nd Choice:

 Gary C. Bernard, MD – (Orange Park location)
 Leiah Walrod, MD – (Orange Park location)
 Keisha Pugh, ARNP – (9A & Baymeadows Rd location)


Preferred Appointment Date

Preferred Appointment Time

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