Request an Appointment Appointments Appointments Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment. Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you! First Name * Last Name * Phone * Email * Preferred Date * Preferred Time * Preferred Time * Morning Afternoon Evening Nature of Visit * Submit If you are human, leave this field blank.