This form is for patients requesting non-urgent appointments only. If you require an immediate appointment please call  General Internal Medicine 397-2738.

* Required Field

Please provide the following contact information:

Name*
Date of Birth*
Work Phone
Home Phone*
E-mail*

Name of your provider at General Internal Medicine:*

 

Appointment requested for: (indicate one)*

yearly breast and pap exam
yearly physical
routine follow up appointment

Please consider the following when scheduling an appointment

The more flexibility in your schedule the greater the likelihood of our being able to offer you an appointment in a timely fashion. While we make every effort to honor your request, choices will also be dependent on your provider's schedule.

 

Appointment preferences:

Month

Day(s)

Time of Day, you may pick more than one.

AM
PM
Evening

Comments:

You will be notified by e-mail of your appointment approximately 48 hours after we receive your request. For weekends allow at least 72 hours. Thank you for using our web site.