Emergent Appointment Request Form

Important Note: This form is for urgent or emergent appointment scheduling. If you are experiencing a life-threatening medical emergency, please dial 911 or proceed to the nearest emergency room immediately.

Patient Information

Patient Name

Date of Request

Appointment Type

Please select your preferred method for this appointment:

In-Person (At the clinic)

Telehealth (Virtual)

Requested Duration

Please select the amount of time needed for this session

15 Minutes (Quick Check-In)

30 Minutes (Standard Consultation)

45 Minutes (Extended Discussion / Complex Issue)

60 Minutes (Comprehensive Assessment / Multiple Concers)

Reason for Appointment

Please briefly describe the urgent reason or symptoms prompting this request