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?
Yes, within the last 12 months
Yes, but it has been more than 12 months.
No, I am a new patient.
Which office are you visiting today? We offer a limited number of TELEMEDICINE appointments during the COVID-19 pandemic time
Dr. Leppard, Plastic surgery
Full Name (Both first Name last Name are required )
(Last name, First name)
Date of Birth (format 00/00/0000)
(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?
Cell Phone Number
Do you have Insurance? You can check here for a complete list of insurances we accept (
). 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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