First Name:

Last Name:

Middle Initial:

Daytime Phone:
( ) - Ext. (e.g. 123-456-7890 Ext. 500)

Have we seen you as a patient before?
Select One Yes No

At what location would you like to be seen?
Select One Muncie, Indiana Richmond, Indiana

Day of week requested:
Select One Monday Tuesday Wednesday Thursday Friday

Time requested:
(9:00 a.m. to 4:00 p.m.)

Comments:

You will be contacted within two business days at the provided phone number to verify your appointment. We will try to accommodate your requests, when possible.

* You may need to check with your insurance carrier to see if a specific doctor or type of doctor is required.