Contact Us Form

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Call </span> <a class="utility-nav__link" href="tel:+17865962373">1-786-596-2373</a></span> <span class="utility-nav__item"> <a class="utility-nav__link languageSwitcher" href="/es/international-services">Español</a></span> <span class="utility-nav__item"> <a class="utility-nav__link" href="https://careers.baptisthealth.net/us/en">Careers</a></span> <span class="utility-nav__item"> <a class="utility-nav__link" href="https://baptisthealth.net/baptist-health-foundation/giving">Giving</a></span> </div> <div class="utility-nav__items-right"> <span class="utility-nav__item"> <a class="utility-nav__link external" href="https://baptisthealth.net/pay-a-bill">Pay a Bill</a></span> <span class="utility-nav__item"> <a class="utility-nav__link button--utility" href="/patient-resources/my-baptist-health-account">Sign In to My Account</a></span> </div> </nav> </div> </div> <div class="global-header__header-bar"> <div class="header-bar"> <div class="container--outer"> <div 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class="header-bar__main-menu"> <button class="button--main-menu desktop-menu-button" type="button">Menu</button> </div><button id="buttonSearch" class="button button--search ctas__button" type="button"><span>Search</span></button> <a class="button button ctas__button ctas__button--apt" href="/international-services/contact-us" aria-label="Contact Us">Contact Us</a> </div> </div> </div> </div> </div> </div> <div class="global-header__menus"> <input id="mainMenuCheckbox" class="menus__hamburger-input" type="checkbox" name="menu-toggle" value="hamburger-link" aria-label="system-menu"> <div class="menus__search"> <div class="container--outer"> <div class="menus__search__container"> <div class="container--inner"> <div class="search_form"> </div> <button class="close-menu close-search element-focusable">Close Search</button> </div> </div> </div> </div> <div class="menus__overlay"> </div> </div> <div class="coe-menu"> <div class="container--outer"> <nav class="coe-menu__nav wrapper resize-drag"> <div class="coe-menu__top-buttons"> <a class="button button--secondary button--small button--full" href="https://baptisthealth.net/patient-resources/my-baptist-health-account">Sign In to My Account</a> <a class="button button--secondary button--small button--full languageSwitcher" href="#">Espa帽ol</a> </div> <ul class="coe-menu__items"> <li class="coe-menu__item coe-menu__item--has-dropdown"> <a class="coe-menu__link" aria-haspopup="true" href="/international-services/international-patients">International Patients</a> <button class="coe-menu__toggle" type="button"><span class="element-invisible">Open Drawer</span></button> <div class="coe-menu__children "> <h3 class="coe-menu__dropdown-parent"><a class="coe-menu__dropdown-parent-link button-text" href="/international-services/international-patients" >International Patients</a></h3> <ul class="coe-menu__list"> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-patients/why-choose-baptist-health">Why Choose Baptist Health</a> </li> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-patients/services-for-international-patients">Services for International Patients</a> </li> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-patients/electronic-second-medical-opinions">Electronic Second Medical Opinions</a> </li> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-patients/executive-health">Executive Health</a> </li> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-patients/accepted-insurance">Accepted Insurance</a> </li> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-patients/preparing-for-your-visit">Preparing for Your Visit</a> </li> </ul> </div> </li> <li class="coe-menu__item coe-menu__item--has-dropdown"> <a class="coe-menu__link" aria-haspopup="true" href="/international-services/international-healthcare-professionals">International Healthcare Professionals</a> <button class="coe-menu__toggle" type="button"><span class="element-invisible">Open Drawer</span></button> <div class="coe-menu__children "> <h3 class="coe-menu__dropdown-parent"><a class="coe-menu__dropdown-parent-link button-text" href="/international-services/international-healthcare-professionals" >International Healthcare Professionals</a></h3> <ul class="coe-menu__list"> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-healthcare-professionals/conferences-and-continuing-medical-education">Conferences and Continuing Medical Education</a> </li> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-healthcare-professionals/international-observerships">International Observerships</a> </li> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-healthcare-professionals/international-collaborations">International Collaborations</a> </li> <li class="coe-menu__child"> <a class="coe-menu__child-link" href="/international-services/international-healthcare-professionals/refer-a-patient">Refer a Patient</a> </li> </ul> </div> </li> </ul> <div class="coe-menu__bottom-buttons"> <nav class="dropdown-utility__items"> <a class="dropdown-utility__link external" href="https://baptisthealth.net/pay-a-bill">Pay a Bill</a> <a class="dropdown-utility__link " href="tel:+17865962373">Call 1-786-596-2373</a> <a class="dropdown-utility__link " href="https://careers.baptisthealth.net/us/en">Careers</a> <a class="dropdown-utility__link " href="https://baptisthealth.net/baptist-health-foundation/giving">Giving</a> </nav> </div> <button class="close-menu close-main-menu element-focusable" type="">Close Main Menu</button> </nav> </div> </div> </header> <section class="page-header page-header--texture has-image-medium page-header--centered "> <div class="container"> <div class="l-page-header-grid"> <div class="page-header__breadcrumbs"> <nav class="breadcrumb" role="navigation" aria-labelledby="system-breadcrumb"> <h2 class="visually-hidden">Breadcrumb</h2> <ol id="system-breadcrumb"> <li> <a href="/international-services"> International Services </a> </li> <li> <a href="/international-services/contact-us"> Contact Us </a> </li> <li> Contact Us Form </li> </ol> </nav> </div> <div class="page-header__content"> <div class="page-header__content-inner"> <h1 class="page-header__title heading--display">Contact Us</h1> </div> </div> </div> </div> </section> <section class="section body-copy "> <div class="container grid--minor-major"> <div class="body-copy__aside l-minor-major--1"> <aside class="aside-content"> <nav class="section-nav" aria-label="section-navigation"> <div class="section-nav__wrap"> <button class="button--secondary button--down-arrow button--full section-nav__trigger" type="button">Section Navigation</button> <div class="section-nav__dropdown"> <h2 class="section-nav__parent"> <a href="/international-services/contact-us" class="section-nav__parent-link">Contact Us</a> </h2> <ul class="section-nav__links"> <li class="section-nav__item"> <a href="#" class="section-nav__link">Contact Us Form</a> </li> <li class="section-nav__item"> <a href="/international-services/contact-us/newsletter-sign-up-form" class="section-nav__link">Newsletter Sign-Up Form</a> </li> </ul> </div> </div> </nav> <script> $('li.section-nav__item.with-children .accordion.side-navigation__icon').click(function () { $(this).toggleClass('open'); $(this).parent().find('ul').slideToggle(); }); </script> </aside> </div> <div class="body-copy__main l-minor-major--2"> <div class="typeset"> </div> </div> </div> </section> <main id="main"> <div class="container"> <div class="container--inner"> <div><section class="section body-copy " data-uw-styling-context="true"> <div class="container" data-uw-styling-context="true"> <div class="body-copy__wrap" data-uw-styling-context="true"> <div class="container--inner" data-uw-styling-context="true"> <div class="typeset default-body" data-uw-styling-context="true"> <p> </p>      <meta http-equiv="Content-type" content="text/html; charset=UTF-8" />    <script src="https://ajax.googleapis.com/ajax/libs/jquery/2.1.1/jquery.min.js"></script> <script type = "text/javascript"> function isNumber(evt) { evt = (evt) ? evt : window.event; var charCode = (evt.which) ? evt.which : evt.keyCode; if (charCode > 31 && (charCode < 48 || charCode > 57)) { return false; } return true; } </script> <style> input[type="date"]::-webkit-input-placeholder{ display:initial !important; } input::-webkit-calendar-picker-indicator{ display: initial !important; } .dateInput input { font-size: .9em; line-height: 1.80556em; -webkit-transition: all .3s ease; transition: all .3s ease; width: 100%; outline: 0; background-color: #fff; border: 1px solid #c4c4c4; border-radius: 5px; color: #222; -webkit-appearance: none; -moz-appearance: none; appearance: none; padding: .75em; } .dateInput input.error{ border:solid 1px red; } .dateInput input:hover, .dateInput input:focus { border-color: #00b288; } .dateInput input.error, .dateInput input.error:hover, .dateInput input.error:focus { border:solid 1px red; } </style> <form action="https://webto.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8" name="formData" method="POST"> <input type="hidden" name="oid" value="00Dd0000000don2" /> <input type="hidden" name="retURL" value="https://baptisthealth.net" />        <div style="display:none;"> <label for="lead_source" style="display:none;">Lead Source</label><select id="lead_source" name="lead_source">--None-- <option value="Advertisement">Advertisement</option> <option value="Employee Referral">Employee Referral</option> <option value="External Referral">External Referral</option> <option value="Partner">Partner</option> <option value="Public Relations">Public Relations</option> <option value="Seminar - Internal">Seminar - Internal</option> <option value="Seminar - Partner">Seminar - Partner</option> <option value="Trade Show">Trade Show</option> <option value="Web" selected="selected">Web</option> <option value="Word of mouth">Word of mouth</option> <option value="Other">Other</option> </select> Contact Type:<select id="00Nd0000005Ubo8" name="00Nd0000005Ubo8" title="Contact Type"> <option>--None--</option> <option value="Domestic Patient">Domestic Patient</option> <option value="Family">Family</option> <option value="Government">Government</option> <option value="Hospital">Hospital</option> <option value="Insurance/TPA">Insurance/TPA</option> <option value="International Patient" selected="selected">International Patient</option> <option value="Physician">Physician</option> </select></div> <label for="first_name">First Name</label><input id="first_name" maxlength="40" name="first_name" size="20" type="text" required/><br /> <label for="last_name">Last Name</label><input id="last_name" maxlength="80" name="last_name" size="20" type="text" required/><br /> <label for="email">Email</label><input id="email" maxlength="80" name="email" size="20" type="text" pattern="^[a-z0-9!#$%&'*+/=?^_`{([|\])}~-]+(?:\.[a-z0-9!#$%&'*+/=?^_`{([|\])}~-]+)*@(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\.)+([a-zA-Z0-9]{2,})$" required /><br /> <label for="phone">Phone</label><input id="phone" maxlength="40" name="phone" size="20" type="text" onkeypress="return isNumber(event)" required /><br /> <label for="00Nd0000005UboI">Country Code</label> <br /> <select id="00Nd0000005UboI" name="00Nd0000005UboI" title="Country Code" width="400" class="salesforceCaptchaFormSelect" required> <option 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BD</option> <option value="BARBADOS - BB">BARBADOS - BB</option> <option value="BELARUS - BY">BELARUS - BY</option> <option value="BELGIUM - BE">BELGIUM - BE</option> <option value="BELIZE - BZ">BELIZE - BZ</option> <option value="BENIN - BJ">BENIN - BJ</option> <option value="BERMUDA - BM">BERMUDA - BM</option> <option value="BHUTAN - BT">BHUTAN - BT</option> <option value="BOLIVIA - BO">BOLIVIA - BO</option> <option value="BOSNIA AND HERZEGOVINA - BA">BOSNIA AND HERZEGOVINA - BA</option> <option value="BOTSWANA - BW">BOTSWANA - BW</option> <option value="BOUVET ISLAND - BV">BOUVET ISLAND - BV</option> <option value="BRAZIL - BR">BRAZIL - BR</option> <option value="BRITISH INDIAN OCEAN TERRITORY - IO">BRITISH INDIAN OCEAN TERRITORY - IO</option> <option value="BRUNEI DARUSSALAM - BN">BRUNEI DARUSSALAM - BN</option> <option value="BULGARIA - BG">BULGARIA - BG</option> <option value="BURKINA FASO - BF">BURKINA FASO - BF</option> <option value="BURUNDI - BI">BURUNDI - BI</option> <option value="CAMBODIA - KH">CAMBODIA - KH</option> <option value="CAMEROON - CM">CAMEROON - CM</option> <option value="CANADA - CA">CANADA - CA</option> <option value="CAPE VERDE - CV">CAPE VERDE - CV</option> <option value="CAYMAN ISLANDS - KY">CAYMAN ISLANDS - KY</option> <option value="CENTRAL AFRICAN REPUBLIC - CF">CENTRAL AFRICAN REPUBLIC - CF</option> <option value="CHAD - TD">CHAD - TD</option> <option value="CHILE - CL">CHILE - CL</option> <option value="CHINA - CN">CHINA - CN</option> <option value="CHRISTMAS ISLAND - CX">CHRISTMAS ISLAND - CX</option> <option value="COCOS (KEELING) ISLANDS - CC">COCOS (KEELING) ISLANDS - CC</option> <option value="COLOMBIA - CO">COLOMBIA - CO</option> <option value="COMOROS - KM">COMOROS - KM</option> <option value="CONGO - CG">CONGO - CG</option> <option value="COOK ISLANDS - CK">COOK ISLANDS - CK</option> <option value="COSTA RICA - CR">COSTA RICA - CR</option> <option value="COTE D'IVOIRE - CI">COTE D'IVOIRE - CI</option> <option value="CROATIA 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