Appointment Information Request Form

Select the items that apply, and then let us know how to contact you.

I would like to make an appointment

Physician -- Dr. Allen -- Dr. Rutkowski -- Dr. Zielinski Physical Therapist -- Bonnie Wagoner -- Kee Miller -- Helen Hagan-Ritz Accounting Choose a category

Enter Preferred Date (must be in mm/dd/yyyy format, i.e. June 30, 1999 should be entered as 06/30/1999)

Enter Preferred Time (must be in hh:mm format, i.e. 10:00)

AM PM Choose AM or PM

NOTE: Our normal operational times are Monday through Friday from 08:30 AM to 05:00 PM
We will do our very best to accomodate requested appointment times; however, we can not guarantee that we will be able to do so. We will contact you as soon as possible with either confirmation of your requested appointment time or with the next closest available time to your request. Thank you for your understanding.

I would like to change an existing (confirmed) appointment

I would like to cancel an appointment