Locations

e-Appointment Request for
AdventHealth Medical Group Primary Care

If you are currently experiencing serious or emergency symptoms please do NOT submit an appointment request. Instead, call 911.

If you submit an appointment request online, please check your email for your appointment date and time. Your email will serve as your confirmation.

Please bring your insurance card, photo ID and your copayment to your appointment. Payment is expected at the time of service. If you need to cancel an appointment, please call the NurseLine at 913-676-7777. Please note there is a cancellation fee of $50 if an appointment is cancelled within 2 hours of the scheduled appointment time.

Please verify your insurance is accepted with the office prior to your appointment.

Submissions will be handled 8 a.m.-2 p.m., Monday-Friday, excluding holidays. If you have a request outside of those hours, or need to speak with a nurse, please call us at 913-676-7777 anytime, 24 hours a day, 7 days a week.

Patient First Name

Patient Last Name

Patient Date of Birth

Gender

Submitter's First Name

Submitter's Last Name

Relationship to Patient

Address

City

State

Zip Code

Reason for Appointment

(Please be as specific as possible so we can find an appropriate time slot for your appointment. Please note exact symptoms and how long when possible. (e.g.: severe sore throat x 2 days). Women: if requesting a physical, please note whether or not you would also like a pap test).

How Soon?

Day of Week First Choice

Day of Week Second Choice

Preferred Time

Primary Phone Number

Alternate Phone

Permission to leave voicemail?

Yes

Appointment Type

Insurance Company

Preferred Doctor

Have seen this doctor before?

Yes

Consider another doctor in this practice?

Yes

Policy Holder

Policy Holder Date of Birth

Insurance Carrier

Insurance Address

Copay Amount

Member ID #

Group #

Comments

Hp county

e-Appointment Request forAdventHealth Medical Group Primary Care

e-Appointment Request for
AdventHealth Medical Group Primary Care