Beckman & Associates - Premier Pediatric Therapy Clinic of Central Florida

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Please choose two appointment dates, in order of preference

First Name

Last Name

Date of Birth

Email

Day time phone

Morning

Afternoon

Either

Yes

No

Primary

Secondary

Yes

No

Yes

No

If your insurance is an HMO, who is your primary care physician?

Phone

Email

What time of day would you prefer ?

Have you ever been a patient at Beckman & Associates before ?

If so, approximately when ?

In the box below please inform us for the reason for your visit and / or any additional information you wish to provide us with.

If you will be using insurance coverage for this visit, please indicate your carrier(s)

HMO?

HMO?

How would you like us to confirm you appointment ?

This is preferred and the fastest method of confirmation, be sure the phone field is filled in

Be sure that the email field is filled in