Appointment request

About you

Full name*

Date of birth*

Telephone

Please give at least a telephone number or an email address so the office can reach you.

How to reach you

The office will contact you using the method you prefer to confirm your appointment.

Best way to reach you*

Telephone callVoicemail is okayText messageEmail

Best days or times to reach you

About the visit

Are you a new or established patient?*

New patientEstablished patient

Type of visit*

Preferred visit format*

In officeTelehealthNo preference

Preferred dates or times for the appointment

Insurance plan, if any

Anything the scheduler should know (optional)

Scheduling details only, please — do not include medical or mental-health information here.

Acknowledgement

Acknowledgement*

I understand that submitting this request does not book an appointment and the office will contact me to confirm a date and time. This website is not monitored in real time. In an emergency I will call 911, or call or text 988 for a mental health or suicide crisis.

I have read and agree to the statement above.

Type your full name as an electronic signature*

Date*

Submitting sends your answers directly to K. Johns Medical over an encrypted connection and creates a PDF for your clinician. It does not book an appointment and is not monitored in real time. For an urgent concern, call the office. In an emergency, call 911 or call or text 988.

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