Contact Us

Patients First Family Medicine

11663 Countryway Boulevard
Tampa, FL 33626
813.891.6310 		6918 Gunn Highway
Citrus Park, FL 33625
Our email for refills is refills@patients-first.com
For Receptionist Questions appointment@patients-first.com
Office Manager manager@patients-first.com
**Please note that email is not a secure form of communication according to the HIPAA privacy act, and specific questions related to your health can not be guaranteed to be secure.

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Patients Portal

Appointment Request
For established patients only.
*Name:

*Email:

*Phone:

*Reason for appointment:

*DOB:

*Provider:

*Date Requested:

Time Requested:

Comments:
*Required Field
Prescription Refills
3 days are required to process refill requests!
If multiple refills needed, please use separate requests.
*Name:

*Email:

*Phone:

*DOB:

*Medication name, dose, and frequency taken:

30 day or 90 day refills?
30 Day 90 day
*Pharmacy name:

*Pharmacy phone:

Comments:

*Required Field
Referrals
*Name:

*Email:

*Phone:

*Date of birth:

*Reason for referral:

*Specialist name and specialty:

*Specialist phone:

*Specialist fax:

*Date of appointment:

*Insurance company:

*Insurance group number:

*Policy number:

*Required Field
Billing
*Patients Name:

*Email:

*Date of birth:

*Contact number:

Questions:
*Required Field
Questions/Comments
*Name:

*Email:

*Contact number:

Question:
*Required Field