Request an Appointment

Schedule

Complete the form below to request an appointment at Miami Pain & Diagnostics. An appointment representative will contact you within two business days to review your medical and financial information, including insurance coverage, before an appointment may be offered.

All fields are required unless marked optional

Desired Date

Desired Time

Patient Information

Please provide patient information as it appears on legal documents.

First Name *

Last Name *

E-mail

Phone Number *

Have you previously received care at Miami Pain & Diagnostics:
 yes no


Patient Insurance Information

Do you have health insurance?

 yes no

Insurance company name

Type of Plan
 HMO


Medical Concern

What is the medical problem or diagnosis for your appointment request?

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