Scheduling

To request an appointment, please do one of the following:

Call 765-741-8843 or 800-522-2590 during business hours.
Complete the form below and submit it to us by pressing the submit button. We will contact you asap to confirm your appointment availability. Your appointment will not be final until we speak with you.
If you would prefer, you can print this page, fill it out, and fax it to us at 765-741-8853. However, as with the option above, your appointment will not be final until we speak with you to verify the date and time.

Schedule Appointment

Scheduled By *
Patient
Physician

Patient's Name *

Patient's Date of Birth *

Patient's Insurance Company *

Primary Phone *

Alternate Phone *

First Choice Date *

Time *

Second Choice Date *

Time *

Referring Physician *

Exam Needed *

Reason or Symptoms *

Additional Info