Appointment Request

To Candida Fink MD
165 Brookdale Avenue
New Rochelle NY 10801
Phone 877-534-1090
Fax 914-637-1077

Please enter all requested information and fax your appointment request to our office.

Patient's Name:
Date of Birth:
Please select the type of appointment you need. Choose only one.		___ 30 minutes ___ 45 minutes ___ 1 hour ___ 90 minute child intake ___ 60 minute adult intake
When do you need this appointment?
Which times are best for you? Mark all that apply. After school appointments are scarce; please book in advance		___ Mondays 11:30-3:30 ___ Tuesdays 12:30-2:00 ___ Tuesdays 3:00-7:00 ___ Wednesdays 11:30-1:00 ___ Wednesdays 2:00-6:00 ___ Thursdays 11:00-12:30 ___ Thursdays 1:00-4:30
Home Phone:
Work Phone:
Cell Phone:
Email Address: