Please note: We cannot process emergency requests through this form. If you are experiencing a medical emergency, please call 9-1-1.

This form cannot be used to schedule same-day appointments. For same-day appointments in Cleveland, please call 216.444.CARE.

To schedule an appointment by phone, please call the appropriate Toll-free number:

  • Cleveland: 866.320.4573 (7am - 11pm EST M-Sun)
  • Florida: 877.463.2010 (7am - 6pm EST M-F)
  • Canada: 888.507.6885 (8am - 5pm EST M-F)

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Patient Information:

The person who will be seeing the physician.

  1. (Tip: Use Address Line 2 if more than 25 characters required in Address Line 1)

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Appointment Details:
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  2. Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.) 500 characters maximum.

  3. Preferred day of the week / date / time of day or first available.

    Preferred physician or provider name.

    We cannot guarantee exact scheduling, but we will do our best to accommodate the patient's wishes.

Requestor Information:

The person completing this form.

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