Appointment Request

Please fill out the form below to request an appointment. Carol will get back to you available times based on the information you provide.

Online forms are provided as a convenience for patients who choose to use them, and reasonable steps have been taken to secure form data.

The fields marked with (*) are required fields.

Your name *

Your email address *

Your cell phone number *

Your secondary phone number

Patient name *

Patient date of birth *

Has the patient seen Dr. Fink before? *

Yes

No

What type of appointment are you requesting: *

Intake- first visit

Routine follow up

A particular concern

OtherOther

Preferred appointment day *

Tuesday

Wednesday

Thursday

Friday

What time of day would you prefer *

11 AM to 2:30 pm

4 to 8 pm

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Additional information, if needed

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