Patient Appointment Request
Thank you for contacting SIMED to request an appointment. Please be aware that it may take 1-2 business days for a response.

By entering as much information as possible we will be able to route your request more efficiently.

I am new to SIMED and wish to make a new patient appointment
I have already seen a SIMED provider and wish to make a return appointment or an appointment with a different provider.

Patient Information
Name:  *
Address:
City:    State:    Zip:
Date of Birth:    

Contact Information
Email:
Phone #:  *
Best time to call:

Appointment Information
I would like to seen in the office at:
I would like to make an appointment within the following specialty:
I would like to make an appointment with the following provider(s):
Hold CTRL to select more than one

Insurance Information
The following information is optional, however providing this information will expedite your request.
Insurance Carrier Name:
Is this an injury related to Worker's Compenstation? 
Is this an injury related to an Auto Accident? 

 I understand that by submitting my request I may be providing Personal Health Information (PHI) to SIMED and that this PHI may be viewed by employees or staff of SIMED (check the box if you agree).

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