I am a(n):
Established Patient
New Patient
Last Name:
First Name:
Date Of Birth: Month(XX), Day (XX), Year (XXXX)
Home Telephone Number:
Cellphone Number:
Work Telephone Number:
Email Address:
Street Address:
Apartment or Unit Number:
City:
State:
Zip:
Insurance:
Aetna
Blue Choice HMO, POS, PPO
Blue Cross Blue Shield
Choice Care Humana PPO
Cigna PPO/HMO/POS
Humana HMO, PPO, POS
CCN (Community Care Network)
First Health
Great West HealthCare PPO/HMO/POS
Other
Private Healthcare Systems (PHCS)
Self-Pay
Southcare/Coventry Healthcare of GA
State Health PPO
High Deductible PPO
Managed Indemnity
Tricare/Champus PPO
Unicare
United Healthcare
Group ID:
Plan ID:
Type of Appointment Requested:
Annual
Consultation
Follow-up
Gynecological Problem
Obstetrical
Postpartum
Referral for Surgery
Second Opinion
Check Preferred Days for Appointment:
Monday
Tuesday
Wednesday
Thursday
Friday
Check Preferred Times for Appointment:
Anytime
Early AM (8:30AM-10:00AM)
Late AM (10:00AM-11:30AM)
Early PM (1:00PM-3:00PM)
Late PM (3:00PM-4:30PM)
I understand that I do not have an appointment with Dr. Randell until I have been contacted by the office and an appointment has been confirmed.
Yes
Please tell us how we can be of further assistance to you.