Please take a few minutes to complete this form to request an appointment with Dr. Kaplan. To expedite your request, please provide as much information as you can in the area below. We value your privacy and therefore, your personal information will not be used by us other than to schedule an appointment. If you prefer, you may speak to us personally anytime between 8:30 am and 4:30 pm Eastern Standard Time, Monday through Friday. Please call us at 954.379.4848.
Your Name (If requesting an appointment for someone else.)
  First Name Middle Initial Last Name    
Title
Please indicate the best time to call you.
Phone Number
(Include country code if outside the U.S.)
  Country Code Area Code Phone Number  
Relationship To Patient
  (If requesting an appointment for someone else.)
* Patient's    Name     
  First Name Middle Initial Last Name    
* Title
* Sex
* Patient's    Date
   of Birth 
   
  Month Day Year
* Address   
  Number Street Apartment    
 
  City State/Province Zip/Postal code Country (If outside the U.S.)
Please indicate the best time to call you.
* Phone    Number
  Country Code Area Code Phone Number (Include country code if outside the U.S.)
Primary Email Address (optional):
Please list your health insurance plan
Is your health insurance an HMO?
Did a physician refer you?
What is your diagnosis?
Are you seeking?
Please add any other information you believe would be helpful
Note: We will make every effort to process your request as quickly as possible. This form is not for urgent appointments or for appointments that you may need today. If you need emergency help, please call 911 or go to your local emergency room.
Please check to be sure that all information in this form is correct before submitting.
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