Please select the best answer below
Type of Appointment
New Patient - Fertility Evaluation/Testing
HSG (Female Fertility Test) - Referral
Semen Analysis - Referral
I Just Have an Appointment Related Question
Note: All HSG’s are performed at the North Tampa location.
If you have a physician referral, please enter the physician's name
Referring Physician Name
Insurance Information
Insurance Plans Currently Accepted
Please select your plan or self-pay
Aetna: Basic, PPO, POS, HMO, EPO, MC (Managed Care)
Baycare: PPO
BCBS: PPO, BlueCare, Blue Options, Blue Select, Network Blue
Beech Street: PPO
CIGNA: PPO, HMO, POS
CIGNA/Great West: PPO
Coventry: PPO
Evolutions: PPO
First Health: PPO
Humana: PPO, HMO, Premier
Multiplan: PPO
PHCS: PPO
United Health Care: PPO, HMO
Appointment Information
Preferred Location:
Brandon
Clearwater
North Tampa (USF area)
South Tampa
Preferred Appointment Time:
Morning
Mid-Day
Afternoon
First Available
First Name
*
Last Name
*
Address
Street Address
*
Street Address Line 2
Apt. Number
City
*
State
*
Postal / Zip Code
*
Phone Number (To confirm your appointment)
*
-
Area Code
Phone Number
Email
*
example@example.com
Fertility Concerns/Questions:
Enter the message as it's shown
*
Request Appointment
Should be Empty: