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Have you seen a doctor at Island Medical Specialists before ?*

YesNo
Please select the doctor you have seen before*
Patient Demographic Data

Please complete the form below to request a consultation appointment with any of our doctors. A member of our team will reach out to you with the next available appointment date and time
Patient's Last Name*
Please enter your name as it appears on your official ID
Patient's First Name *
Please enter your name as it appears on your official ID
Patient's Middle Name / Initial
Patient's Title*
Date Of Birth*

YearMonthDay
Date
Please upload a clear picture or scan of your ID here.

ID Type : driver's license , Passport , or National ID
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Address*

Street Address

Street Address Line 2

CityParish / State / Province

Postal / Zip Code
Patient's Phone Number*
Please enter a valid phone number.
Patient's Email
example@example.com
REFERRAL FORM

Please upload your referral form below if you have it handy, but don't worry if you don't. You can always bring your referral letter along when you visit:
Please upload a clear picture or scan of your referral

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REPORTS

Please upload any lab or imaging reports you may have. If you're unable to upload them, kindly remember to bring these documents with you when you visit. Having your reports on hand helps ensure that we can provide the best care during your appointment.
Please upload a clear picture or scan of your lab or imaging reports

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INSURANCE

This section is optional: Feel free to bring your insurance card with you when you visit us.
Insurance

CanopyGuardianSagicorOther
Other Insurance
Please upload a clear picture of scan of your insurance card

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Emergency Contact Information

Emergency Contact information is used in case an IMS representative is unable to get to you using the information provided or in case of an emergency.
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Relationship
Emergency Contact 2 Name

First NameLast Name
Emergency Contact 2 Number
Please enter a valid phone number.
Relationship
APPOINTMENT DETAILS

Please select the doctor you wish to see from the drop down list below. Feel free to add any additional information you need us to know so we can best schedule you.
Do you already have an appointment with the doctor you wish to see??*

YesNo
Please select the doctor you are booked to see *
Please select the doctor you wish to see*
Please provide any additional information you believe is necessary for scheduling your appointment
Should be Empty:

Patient Demographic Data

REFERRAL FORM

REPORTS

INSURANCE

Emergency Contact Information

APPOINTMENT DETAILS