APPOINTMENT REQUEST

This appointment request form is being provided to you for your convenience. Please complete this form and a receptionist from our office will contact you by phone to schedule your appointment. Thank you.

PLEASE NOTE:

IF THIS IS A MEDICAL EMERGENCY, PLEASE CALL 911.

IF THIS IS AN ACUTE PROBLEM THAT NEEDS MEDICAL ATTENTION NOW, PLEASE CALL OUR OFFICE AT 754.3863.

*Last Name:
*First Name:
*Date of Birth: (mm/dd/yyyy)
*Daytime Phone:
*Evening Phone:
Email:
What type of appointment do you need?	General Health Care Recheck (Follow-up) Adult Physical Women's Annual Exam/PAP/GYN Well-Child Physical Camp/College/Sports Physical Labwork Laser for Hair Removal Massage Acupuncture Obagi (Skin Care) Dexa (Bone Density) Smoking Cessation Reiki E.T.P.S. (Electro Therapeutic Point Stimulation) Other
*How soon do you need this appointment?	First Available Less Than a Week Within a Month 1-2 Months 2 Months or more
*Best time for an appointment?	AM     PM     Evening     ASAP
*Best time to call you?	AM     PM     Evening     ASAP
*Best day for an appointment?	No Preference  Monday  Tuesday  Wednesday  Thursday  Friday
Do you have a Provider preference?	--Select-- Bruce Bowling, MD Kimberly Desantis, MD Victor Elinoff, MD Lazarus Gehring, MD Jonathan Harris, MD Karen Hiester, DO James C. Holler, MD Rekha Patel, MD Suchet Patel, MD John Perry, MD Duncan Sze-Tu, MD Michael H. Tunick, DO Gloria J. Block, RN, FNP Ann Marie LaMarca Major, FNP-C Sue Puglisi, FNP-C
We will make every attempt to contact you by phone within 24 hours. Requests made after Friday 3pm will be answered on the following Monday. Requests made on a holiday will be answered on the next business day. If you are not contacted by EFP within this time frame, please assist us by calling the office at 754.3863. Thank you, Your Healthcare Team at EFP