Bartow PPM - Appointment Form Request

Appointment Request Form Please complete the appropriate form that best suits your needs.

If you need immediate assistance, please call us during office hours. The appointment request form is not to be used in case of emergencies, if this is an emergency dial 911.

* Indicates a required field

Your Contact Infomation * First Name:

* Last Name:

* Phone:

* Email:

Your Appointment Time Which doctor do you wish to see?

Rafael Quinones, MD

Stanley H Shrom, MD

Preferred days:

Preferred times:

Request a specific date and time:

How did you hear about us?:

How did you hear about our web site?:

Insurance Carrier:

Primary Care Physician or Referring Physician:

Comments Let us know how we can help

Please type the color of the first character:

Send your information