Appointment Request Form

Appointment Request Form

As an alternative to phoning our offices for medical appointments, South Bay Family Medical Group has established this portion of our Web content to allow you to request an appontment online. It is not for emergency situations. In the case of an emergency, call 911 or go to the nearest hospital emergency room.

If you have an urgent medical problem, please call our office:

Redondo Beach Office: ��(310) 374-9646
Manhattan Beach Office: (310) 939-7555

We will respond to your e-mailed appointment request Monday - Friday within 48-hours during normal business hours. This service is for the patient who wants to make an appointment for the upcoming week or month - it is NOT for same day or next day appointments. If you require an appointment sooner than two business working days, please call our office at (310) 374-9646.

To make an appointment, please complete this form online and click the "Send" button at the bottom of this page

Name of Patient

Name of person making the appointment (if not the patient)

Relationship to patient

Are you a first-time patient?

Yes

No

I would like to make a non-urgent appointment with:

Redondo Beach Office

Dr. Nancy Griffith

Dr. Mark Howard

Dr. William Kim

Dr. Anna Basile Mellor

Dr. Eric Munro

Dr. Fred Leland Reitler

Dr. Scott Tong

Dr. Lee G. Kissel

Dr. Danette Taylor

Dr. Mary F. Bricken

I need to see the doctor for:

Annual comprehensive physicial

Annual pap smear/well woman exam

Medication follow-up

New medical problem

Re-check on medical condition

School physical

Several medical problems

Well baby check

I don't need to see the doctor. I need to have blood drawn for:

I prefer the following day of the week:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday or Sunday

I prefer an appointment at the following hour:

�� AM�� PM

Patient's birthdate:

If we have questions or there is a scheduling conflict please supply the following information:

Area Code and Home Telephone Number:

Area Code and Work Telephone Number:

E-mail Address: