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Request Appointment

If you are an established patient, please complete the fields below and submit this form to request an appointment. We will attempt to reply to your request by the next business day. Attention: If you do not receive a confirmatory phone call or email by the end of the following business day, please resubmit.

Full Name:
Email Address:
Phone Number::
Date of Birth:

Reason for Visit:
(well visit, sick visit, medication refill, labs, other)
How soon would you like
your next appointment?
 
(within the next week, next month, next 3 months, next 6 months)
What day of the week would
you like to come in?
 
(Monday, Tuesday, Wednesday, Thursday, Friday)
What time of day do you prefer?  
(AM, PM, either)
Which doctor would you like to see?  
(Dr. Shotts, Dr. Blair, Dr. Cerrato, Dr. Robertson, Dr. Stamp, Dr. Merrick)
Additional Comments:  

 
Contact Information

In this area, you can enter text about your contact form. You may want to explain what happens after a visitor submits the form and include a contact phone number.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Comments:

Contact Information

In this area, you can enter text about your contact form. You may want to explain what happens after a visitor submits the form and include a contact phone number.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Comments: