Appointment

Patients are seen by appointment only. When you make an appointment, please let the scheduler know which provider you wish to see, and briefly describe the problem so an appropriate amount of time can be scheduled. If you have several problems to discuss, it is helpful to know in advance.


NOTE: This form should only be used for NON-URGENT appointments.   You can also request an appointment on the patient portal.

If you have an urgent medical problem that needs to be addressed immediately. PLEASE CALL THE OFFICE at 574-936-7777, OR CONTACT THE APPROPRIATE MEDICAL EMERGENCY SERVICE.

Patient Name: *
Date of Birth: *
Provider I would like to see: *
 Location: *
Request Visit Date  and Time: *
Reason for Visit: * *
 Phone Number where you can be reached: *  
 Email Address:   
Please type any additional comments: *
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