Appointment Request

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:

Contact Information

Name*
Date of Birth*
Work Phone
Home Phone*
Email*

Name of your Provider*




Appointment requested for*

routine follow up appointment
yearly breast and pap exam
yearly physical


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 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.


   


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2301 Columbia Avenue Lancaster, PA 17603
Phone - 717.397.2738 Fax - 717.397.7634

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