Request Appointment

Appointment Request
Use this form for non-urgent appointments only.

Your request will be processed within 72 business hours. If you do not hear from us, please contact us by phone.

For urgent appointments within 24 hours, please contact us by phone at 716-837-0995.
Patient Information
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB*

MonthDayYear
Date
Requesting Individual Information
Full Name

First NameLast Name
Email
example@example.com
Relationship To Patient
Daytime Phone*

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Best Time To Contact You

MorningAfternoonEvening
Appointment Information
Are you a new or existing patient?*

NewExisting
What Type Of Appointment Are You Requesting*

SickWellFollow UpMental HealthOther
Preferred Day:

MondayTuesdayWednesdayThursdayFriday
Preferred Time:

48 - 72 HoursOne WeekTwo WeeksThree Weeks
Provider*
Other Information
What insurance do you have?*
Comments
Should be Empty:

Appointment Request