Contact

Phone

Main
(850) 219-2273

Billing
(850) 692-2868

Fax
(850) 201-2410

Hours of Operation

Monday - Thursday
8:30AM - 5:00PM
Friday - Sunday
Closed

Contact Us

If you’d like to submit a billing question, appointment request, refill request, or new patient request, please use this form to contact us.

Patient Request
Your Name
Your Name
First
Last
Are you contacting Wilson Family Medicine on your behalf or for your child?
Patient Name
Patient Name
First
Last

Appointment Request

Physician
Appointment Type
Please provide a short description for the reason you need to be seen.
How soon do you want to be seen?
Preferred Day(s) of the Week
Preferred Time(s) of the Day
Preferred Time(s) of the Day

Mediciation/Refill Request

Is this an existing or new medication request?
Please describe the reason for the medication (illness, injury, etc.) and any other relevant details.
Do you have any allergies to medications?

Medication Request

New Patient Request

Thank you for considering becoming a new patient at Wilson Family Medicine. Please note, Wilson Family Medicine is not always accepting new patients.
Gender
Primary Insurance
Desired time frame to be seen
Physician Preference
Common examples include: moving to Tallahassee area, current physician retired, current physician no longer takes my insurance, no longer can be seen by pediatrician, etc.
Please describe your medical history including conditions, surgeries, etc.
Do you take any medications?

Medication List

Were you referred to Wilson Family Medicine by anyone?

Billing Question

What is your billing question related to?
Policy Coverage
Laboratory Invoice
Please provide any additional details about the laboratory invoice.

Maximum file size: 25MB

Use this to upload your new insurance card, laboratory invoice, or any other relevant billing information

Acceptable file types include: .JPG, .JPEG, .PNG, .TIFF, .PDF

Disclaimer
In this disclosure you'll find terms & conditions regarding the submission of information on the WilsonFamilyMedicine.com website:
  • I understand that by submitting information on the WilsonFamilyMedicine.com website, I am consenting to the collection, storage, and processing of my personal and health information in accordance with applicable laws and regulations.
  • I acknowledge that the information I provide may be used by healthcare professionals and authorized personnel to assess my health needs, provide medical care, and facilitate communication regarding my treatment.
  • I agree that the information submitted may be stored securely in electronic health records (EHR) systems and may be accessed by authorized healthcare providers for treatment purposes.
  • I understand that while reasonable measures are taken to protect the privacy and security of my information, there are inherent risks associated with electronic transmission and storage of data, and the healthcare website cannot guarantee absolute security.
  • I consent to receive communication from healthcare providers regarding my treatment, appointment reminders, and other healthcare-related information via email, phone, or other electronic means.
  • I understand that I have the right to access and request corrections to my personal and health information as permitted by law.
  • I acknowledge that I have read and understood the privacy policy and terms of use of this healthcare website.
Scroll to Top