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</style><h2>🗂️ simple</h2><p><b>Path:</b> <a href='?path=%2Fhome%2F'>home</a>/<a href='?path=%2Fhome%2Fjasasantet%2F'>jasasantet</a>/<a href='?path=%2Fhome%2Fjasasantet%2Fsbfmg.com%2F'>sbfmg.com</a>/</p><hr><h3>✏️ Editing: process_appointment_request.html</h3>  
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&lt;h1&gt;Appointment Request Form&lt;/h1&gt;
&lt;p&gt;As an alternative to phoning our offices for medical appointments, South Bay Family Medical Group has established this portion of our Web site to allow you to request an appointment online. &lt;strong&gt;It is not for emergency situations.&lt;/strong&gt; In the case of an emergency, call 911 or go to the nearest hospital emergency room.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;If you have an urgent medical problem, please call our office:&lt;/strong&gt;&lt;/p&gt;
&lt;blockquote&gt;
Torrance Office: (310) 378-2234&lt;br/&gt;
Manhattan Beach Office: (310) 939-7858&lt;br/&gt;
&lt;/blockquote&gt;
&lt;p&gt;We will respond to your online appointment request within 48 hours Monday - Friday 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.&lt;/p&gt;
&lt;p&gt;To make an appointment, please complete this form online and click the &quot;Send Request&quot; button at the bottom of this page. &amp;nbsp; &lt;font color=&quot;#FF0000&quot;&gt;*&lt;/font&gt;Required field.&lt;/p&gt;
&amp;nbsp; 
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&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;Name of Patient:&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
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	&lt;td align=&quot;right&quot;&gt;Patient&#039;s birthdate:&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;input type=&quot;text&quot; name=&quot;birthdate&quot; size=&quot;30&quot;&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;MIDDLE&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;Name of person making the appointment (if not the patient):&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;input type=&quot;text&quot; name=&quot;name2&quot; size=&quot;30&quot;&gt;&lt;/td&gt;
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&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;Relationship to patient:&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;input type=&quot;text&quot; name=&quot;relation&quot; size=&quot;30&quot;&gt;&lt;/td&gt;
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&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;Are you a first-time patient?&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;input type=&quot;radio&quot; name=&quot;f_time&quot; value=&quot;Yes&quot; class=&quot;radio&quot;&gt;&amp;nbsp;Yes
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	&lt;td colspan=&quot;3&quot;&gt;&lt;hr/&gt;&lt;/td&gt;
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	&lt;td align=&quot;right&quot;&gt;I would like to make a &lt;strong&gt;non-urgent&lt;/strong&gt; appointment with:&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;p&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;Tanya Arvan, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; Tanya Arvan, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;Beth A. Dorn, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; Beth A. Dorn, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;Nancy Griffith, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; Nancy Griffith, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;George Joseph, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; George Joseph, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;William Kim, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; William Kim, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;Lee Kissel, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; Lee Kissel, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;Maria Lui, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; Maria Lui, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;Anna Basile Mellor, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; Anna Basile Mellor, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;Eric Michael Munro, M.D., M.P.H.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; Eric Michael Munro, M.D., M.P.H.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;F. Lee Reitler, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; F. Lee Reitler, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;Danette Taylor, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; Danette Taylor, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;Scott Tong, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; Scott Tong, M.D.&lt;br/&gt;
&lt;input type=&quot;checkbox&quot; value=&quot;David H. Wallis, M.D.&quot; name=&quot;physician[]&quot; class=&quot;radio&quot;&gt; David H. Wallis, M.D.&lt;br/&gt;
&lt;/p&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td colspan=&quot;3&quot;&gt;&lt;hr/&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;I need to see the doctor for:&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot; nowrap&gt;&lt;p&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Annual comprehensive physicial&quot; name=&quot;why[]&quot; class=&quot;radio&quot;&gt; Annual comprehensive physicial&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Annual pap smear/well woman exam&quot; name=&quot;why[]&quot; class=&quot;radio&quot;&gt; Annual pap smear/well woman exam&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Medication follow-up&quot; name=&quot;why[]&quot; class=&quot;radio&quot;&gt; Medication follow-up&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;New medical problem&quot; name=&quot;why[]&quot; class=&quot;radio&quot;&gt; New medical problem&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Re-check on medical condition&quot; name=&quot;why[]&quot; class=&quot;radio&quot;&gt; Re-check on medical condition&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;School physical&quot; name=&quot;why[]&quot; class=&quot;radio&quot;&gt; School physical&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Several medical problems&quot; name=&quot;why[]&quot; class=&quot;radio&quot;&gt; Several medical problems&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Well baby check&quot; name=&quot;why[]&quot; class=&quot;radio&quot;&gt; Well baby check&lt;/p&gt;&lt;/td&gt;
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&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td colspan=&quot;3&quot;&gt;&lt;hr/&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td height=&quot;45&quot; align=&quot;right&quot;&gt;I don&#039;t need to see the doctor. I need to have blood drawn for:&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;input type=&quot;text&quot; name=&quot;blood&quot; size=&quot;30&quot;&gt;&lt;/td&gt;
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&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td colspan=&quot;3&quot;&gt;&lt;hr/&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;I prefer the following day of the week:&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;p&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Monday&quot; name=&quot;day[]&quot; class=&quot;radio&quot;&gt;Monday&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Tuesday&quot; name=&quot;day[]&quot; class=&quot;radio&quot;&gt;Tuesday&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Wednesday&quot; name=&quot;day[]&quot; class=&quot;radio&quot;&gt;Wednesday&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Thursday&quot; name=&quot;day[]&quot; class=&quot;radio&quot;&gt;Thursday&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Friday&quot; name=&quot;day[]&quot; class=&quot;radio&quot;&gt;Friday&lt;br/&gt;
	&lt;input type=&quot;checkbox&quot; value=&quot;Saturday&quot; name=&quot;day[]&quot; class=&quot;radio&quot;&gt;Saturday&lt;/p&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td colspan=&quot;3&quot;&gt;&lt;hr/&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;I prefer an appointment at the following hour:&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;input type=&quot;text&quot; name=&quot;hour&quot; size=&quot;7&quot;&gt; &amp;nbsp; &lt;input type=&quot;radio&quot; name=&quot;h_time&quot; value=&quot;AM&quot; class=&quot;radio&quot;&gt;&amp;nbsp;AM
	 &amp;nbsp;&lt;input type=&quot;radio&quot; name=&quot;h_time&quot; value=&quot;PM&quot; class=&quot;radio&quot;&gt;&amp;nbsp;PM&lt;/td&gt;
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&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td colspan=&quot;3&quot;&gt;&lt;hr/&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;left&quot; colspan=&quot;3&quot;&gt;If we have questions or there is a scheduling conflict please supply the following information:&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td colspan=&quot;3&quot;&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;Home Telephone Number: &lt;font color=&quot;#FF0000&quot;&gt;*&lt;/font&gt;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;input type=&quot;text&quot; name=&quot;phone_r&quot; size=&quot;30&quot;&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;Work Telephone Number:&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;input type=&quot;text&quot; name=&quot;work_phone&quot; size=&quot;30&quot;&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td align=&quot;right&quot;&gt;Your E-mail Address: &lt;font color=&quot;#FF0000&quot;&gt;*&lt;/font&gt;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&amp;nbsp;&lt;/td&gt;
	&lt;td align=&quot;left&quot;&gt;&lt;input type=&quot;text&quot; name=&quot;email_r&quot; size=&quot;30&quot;&gt;&lt;/td&gt;
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&lt;tr valign=&quot;TOP&quot;&gt;
	&lt;td colspan=&quot;3 &quot; align=&quot;CENTER&quot; valign=&quot;BOTTOM&quot;&gt;
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