REQUEST AN APPOINTMENT

Patient Information

First and Last Name*

First Last

Home / Mailing Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth (DOB)*

Where can you be reached during business hours?

Best Phone Number*

Alternate Phone Number

Email*

Enter Email Confirm Email

Insurance Information

Self Pay or Insured?*

Relationship to Patient*

Name of Primary Insured*

Date of Birth (DOB) of Insured*

Specific Insurance Plan Name*

Insurance ID Number*

Insurance Group Number*

Insurance Phone Number*

(Provider Services, Member Services, Customer Service)

Insurance Address to Mail Medical Claims*

About Your Appointment

Telemedicine Video Visits can connect you to your doctor securely through your personal device (computer, tablet, or smartphone) without the need to come into the office. These optional Telehealth visits work for some types of appointments that do not require physical examinations. Most insurance plans cover Telemedicine visits. Cash-pay Telemedicine visits are also available. If you are interested, you may choose this option and our Appointment Setters will notify you if your type of appointment is better suited for or requires a traditional office visit. Did you know? All our in-person cosmetic consultations are complimentary.

Type of Visit: In Office Traditional or Telemedicine Video Visit*

Reason for Traditional, In-Office Visit*

Please note: If you’re pregnant or think you’re pregnant, please call the office to schedule your appointment.

Please Describe the Reason for the Consultation or Concern*

Please Describe Your Concern*

Please Describe*

Please provide the date of the first day of your last period.

Reason for Telemedicine Video Visit*

Please note: If you’re pregnant or think you’re pregnant, please call the office to schedule your appointment. Telemedicine Visits work well for appointments which do not require a physical examination or testing.

Description of Other Type of Visit, Please*

Laser Hair Removal Treatment Areas

Choose as many as apply to this appointment. If you aren't sure, give us your best idea.

Small Treatment Areas

Uni-brow
Upper lip
Chin
Areola
Hands and fingers
Feet and toes
Happy-trail
Peri-anal

Medium Treatment Areas

Cheeks (of face)
Neck
Cleavage
Underarms
Shoulders
Bikini
Glutes

Large Treatment Areas

Desired Office*

Laser Hair Removal is Only Available at Our Riverview Office.

Do you have a specific physician preference?*

First Available
Specific Physician

South Tampa Office Preference*

North Tampa Office Preference*

Lutz Office Preference*

Riverview Office Preference*

Do you have a preferred time of day to be seen for this service?*

Any / Next Available
Early Morning
Late Morning
Early Afternoon
Late Afternoon

Please tell us your preferred time of day for our receptionist to call you to schedule your appointment.*

Morning
Mid-Day
Afternoon
Any

How did you hear about The Woman's Group?*

Please describe how you heard about the Woman's Group*

Optional: For additionl notes, comments, or questions.

This field has a 10,000 character max. That's about 1,500 words or roughly 6 paragraphs.

You may upload updated insurance information here.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 15 MB.

Has your insurance changed? You may upload your new insurance information here. You will still need to bring your card the day of your visit. Thank you.

Phone

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