Appointment Request Form
This is a request form, not a guaranteed appointment. We strive to get back to you as soon as we can, most likely on the same business day if submitted before 4 pm. If the request is on a holiday/weekend, we shall get back to you next business day.
In a few words, please tell us about the purpose of your visit. e.g. "I've had a rash for three weeks". " I need an annual checkup". "There is a growth on my back". *
Have you been to one of our practices before? *
Which office are you visiting today? We offer a limited number of TELEMEDICINE appointments during the COVID-19 pandemic time
Clear selection
Full Name (Both first Name last Name are required ) *
(Last name, First name)
Sex *
Date of Birth (format 00/00/0000) *
Your address *
(Complete address including ZIP code is required to schedule appointment)
We can notify you of your appointment time by either email or a text message to your phone. What is your preferred method of communication? *
email *
Cell Phone Number *
Do you have Insurance? You can check here for a complete list of insurances we accept (https://docs.google.com/document/d/1IYN13RCGbkyBlb6-oTo4QY7ahRAmvctyZJFyZVLMyqY/edit?usp=sharing). For self-pay, a deposit may be required for certain types of appointments. Cosmetic procedures are NOT usually covered in most health insurance plans. *
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