Schedule Diabetic Eye Exam
Share your details so we can help coordinate your appointment and send results back to Brandon Area Primary Care, P.A.
Patient Information
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What insurance do you have?
*
Please Select
Medicare
Aetna Medicare
Humana Medicare
UnitedHealthcare Medicare
Florida Blue Medicare
Other
I’m not sure
Insurance Company Name
Preferred Location
Where would you prefer to have your eye exam?
*
Brandon
Riverview / Apollo Beach
Plant City
Tampa
Closest available location
I already have an eye doctor
Eye Doctor or Practice Name
Appointment Preference
What time of day generally works best for you?
*
Morning
Afternoon
Either
Which days generally work for you?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Any weekday
Authorization
Authorization
*
I authorize Brandon Area Primary Care, P.A. to share the information necessary with an eye care provider to assist with coordinating my diabetic eye exam. I also authorize the eye care provider to communicate appointment status and exam results back to Brandon Area Primary Care, P.A.
Electronic Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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