Request An Appointment [remove after reading, only content that changes is the phone numbers]
Request an Appointment Today
If you would like to request an appointment at our hospital, please fill out and submit the form below, or call us at 555-555-5555 . Please note that this is only a request, someone from our office will contact you shortly to confirm a date and time for your appointment.
For New Patients, please allow an additional 10 to 15 minutes prior to your appointment to create a medical record and patient file.
If your matter is URGENT, or you feel you are experiencing an EMERGENCY, please call us immediately at 555-555-5555 and DO NOT use the form below.