Appointment Request Form

Have you previously been seen by Gastroenterology Associates of Gainesville, P.C.?*
—Please choose an option—YesNo

First Name*

Last Name*

Gender:*
—Please choose an option—MaleFemale

Date of Birth*

Address (Address/City/State/Zip):*

Insurance Carrier:*

Primary Care Physician:

Referring Physician:

Contact Name:

Contact Relationship:
—Please choose an option—ChildGuardianParentSelfSpouseOther

Daytime Phone Number (XXX-XXX-XXX)*

Your Email*

What is the best time to contact you?*
—Please choose an option—AMPM

Reason for appointment:*

Preferred Office Loaction:
First AvailableBraseltonDawsonvilleDemorestGainesville

Preferred Physician:
First AvailableScott A. Clark, MDSheraj Jacob, MDJohn L Kalarickal, MDNamita Pareek, MDVinni M. Reddy, MDNeeraj Sharma, MDAnkur Sheth, MDAndrew Lake, MDNickola Booker, PA-CMarla Dixon, PA-CJoanna Harkness, NP-CJaime Majors-NP-CFeather Holbrook, NP-CMichelle Webb, NP-C

Appointment Preferences:

If you have a day of the week that works best for your schedule, let us know.
We'll check availability in those time slots first.

MondayTuesdayWednesdayThursdayFriday

Agreement/E-Signature Disclaimer
By selecting the "I agree to these conditions" checkbox, you agree to the following: You acknowledge the risk of sending information by email and will not hold Gastroenterology Associates of Gainesville, P.C. responsible for any damages you may incur as a result of the transfer or use of this information. You understand the use or transmittal of this form does not create a physician-patient relationship. You are giving representatives from Gastroenterology Associates of Gainesville, P.C. permission to contact you between 8:00 am and 5:00 pm EST to help you schedule an appointment.

I agree to these conditions

Important: After submission, please do not leave this form until you see the confirmation message.