Make Appointment "*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Are you a new or existing patient?* New Existing This field is hidden when viewing the formContact Info SectionName* First Last Email* Phone*How did you hear about us?* Google Search Facebook Instagram Friend or Family Other Please specifyThis field is hidden when viewing the formScheduling SectionPlease select a date and time below.Date Preference*Appointment requests must be confirmed by staff before they are finalized. Please call the office for urgent requests. MM slash DD slash YYYY /*The datepicker must be given CSS class gform_datepicker_custom*/ gform.addFilter( ‘gform_datepicker_options_pre_init’, function( optionsObj, datepicker_selection ) { /*Select the input for the datepicker with the custom classgform_datepicker_custom*/ var datepicker_selection = document.querySelector(“.gform_datepicker_custom .ginput_container_date input”) /*Ensure the datepicker_selection actually exists on the form*/ if (datepicker_selection !== null) { /*Minimum number of days advance notice*/ optionsObj.minDate = ‘+2’; /*Maximum number of months in advance an appointment can be requested*/ optionsObj.maxDate = ‘+6 M’; optionsObj.beforeShowDay = function(date) { var day = date.getDay(); /*Specific days to block from datepicker*/ return [!(day == 0 || day == 6)]; }; /*Make the datepicker input box readonly so that the datepicker calendar must be used*/ datepicker_selection.readOnly = true; }; return optionsObj; }); Preferred Times Early morning Late morning Around noon Early afternoon Late afternoon Other Other Preferred TimesMessage (Optional)This field is hidden when viewing the formWavier SectionWaiverI acknowledge that I am not including any protected health information (PHI) in my inquiry. I understand that any such information should be presented in person or securely over the phone with my health care provider. PHI, as defined by HIPAA (Health Insurance Portability and Accountability Act) includes, but is not limited to, any information that relates to 1) the past, present, or future physical or mental health or condition of an individual, 2) the provision of health care to an individual or 3) the past, present, or future payment for the provision of health care to an individual that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual. I consent to allow any and all electronic communications with this recipient. These communications include this form and all others on this website, emails, text messages and website comments. I understand that electronic communication is not secure and that any information that I provide here may be visible to third parties or unintended recipients. I waive my rights under HIPAA to the extent that they can be waived and, in the event that any PHI is provided within this message or related messages, do not hold the recipient liable to any breaches or disclosures of the information provided in this message. I acceptCAPTCHA