Contact

Phone

Main
(850) 219-2273

Billing
(850) 692-2868

Fax
(850) 201-2410

E-mail

[email protected]

Address

2621 Mitcham Drive, Ste. 103
Tallahassee, FL 32308

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

Phone *

Are you contacting Wilson Family Medicine on your behalf or for your child? *

For myself

For my child

Patient Name *

Patient Name

First

Last

Patient Date of Birth *

Reason for Contact *

Appointment Request

Physician

Dr. Les Wilson

Dr. Vicki Erwin-Wilson

Appointment Type *

Routine Follow Up

Medication Follow-Up

Adult Annual Physical Exam

Well Child Check

Illness/Injury

BP check/Injection (B12, testosterone, etc.)

OtherOther

Reason For Visit *

Please provide a short description for the reason you need to be seen.

How soon do you want to be seen?

Next available

Within the next few days

Within the next few weeks

Within the next few months

No preference

Preferred Day(s) of the Week

Monday

Tuesday

Wednesday

Thursday

Preferred Time(s) of the Day

9:00am to 1:00pm

2:00pm to 5:00pm

Preferred Time(s) of the Day

11:00am to 1:00pm

2:00pm to 5:00pm

Mediciation/Refill Request

Is this an existing or new medication request? *

Existing Medication

New Medication

Reason for medication *

Please describe the reason for the medication (illness, injury, etc.) and any other relevant details.

Do you have any allergies to medications? *

Yes

Medication Allergies *

Pharmacy Name *

Pharmacy Address *

Medication Request

Medication Name *

Add Remove

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 *

Female

Male

Primary Insurance

Capital Health Plan

Blue Cross/Blue Shield (Florida Blue)

Aetna

Medicare

Cigna

Humana

Tricare

United Healthcare

United Healthcare Medicare Advantage

Self-Pay

OtherOther

Desired time frame to be seen *

As soon as possible

Next few weeks

Next few months

No preference

Physician Preference *

Dr. Les Wilson

Dr. Vicki Erwin-Wilson

No Preference

Current Primary Care Physician *

Reason for switching to Wilson Family Medicine *

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.

Medical History *

Please describe your medical history including conditions, surgeries, etc.

Do you take any medications? *

Yes

Medication List

Medication Name *

Add Remove

Were you referred to Wilson Family Medicine by anyone? *

Yes

Who were you referred by?

Billing Question

What is your billing question related to? *

Wilson Family Medicine Billing Statement

Wilson Family Medicine Insurance Information Update

Laboratory Invoice (Quest, LabCorp, etc.)

Wilson Family Medicine Invoice Number *

Explain Billing Issue or Question *

New Insurance Carrier *

Member ID *

Group Number *

Policy Coverage *

Primary

Secondary

Tertiary

Other

Relationship to Policyowner * Relationship to Policyowner

Policy Effective Date *

Laboratory Invoice *

Recode & Resubmit Laboratory Bill

Other

Laboratory Invoice Details *

Please provide any additional details about the laboratory invoice.

File Upload

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 *

By checking the box, I confirm that I have read, understood, and agree to the terms and conditions outlined below

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.

If you are human, leave this field blank.