Please note that this form is for requesting appointments only. Availability will vary and someone from our office will call you to confirm your appointment request. Please do not submit any Protected Health Information.

NO SHOW: 24 hours’ notice is required for cancellation of your appointment and failure to do so will incur a $50 fee charged directly to you. Failure to provide 24 hours’ notice of an office procedural visit will incur a $75 fee.

SURGERY CANCELLATION: Failure to provide 5 business days’ notice before surgery will incur a $500 fee. Plus, a possible fee from the Surgical Center billed out by them.