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INTEGRATED MEDICAL OF DANBURY
APPOINTMENT REQUEST
THANK YOU FOR YOUR INQUIRY. WE WILL RESPOND TO YOU SHORTLY.
OUR OFFICE DOES NOT ACCEPT ANY URGENT OR EMERGENCY REQUESTS VIA EMAIL.
ALL OFFICE VISITS ARE BY CONFIRMED APPOINTMENT ONLY.
IF THIS IS AN EMERGENCY, PLEASE DIAL 911.
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Email
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Your email
Your name
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Your answer
SERVICE REQUESTED
*
VA Disability Exam
I-693 Immigration Exam-Civil Surgeon
9/11 World Trade Center (WTC) Monitoring Exam
DOT Medical Certificate
Other:
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APPOINTMENT REQUEST, DAY AND TIME
*
OFFICE VISITS BY CONFIRMED APPOINTMENT ONLY.
MM
/
DD
/
YYYY
Time
:
AM
PM
CELL NUMBER
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Your answer
TERMS
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I authorize Integrated Medical of Danbury, LLC to communicate with me via electronic communication, including, but not limited to, secure email, telehealth and the use of HIPAA compliant electronic medical records.
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A copy of your responses will be emailed to the address you provided.
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