Online Appointment Request Form

Patient Information

Legal Name of Patient

Patient's Date of Birth

Parent/Guardian Name (if applicable)

Name of Contact Person

Services Requested

Please indicate the type of services for which you would like an appointment (check one box below). Scheduling staff will be able to answer questions to help you determine which appointment type is best for you.

I would Like to set up an appointment for:

Preference regarding clinician (if any)

Terms for Online Appointment

The information we collect from this website is used only for obtaining information about you for scheduling purposes.

You and MIND or any of it’s healthcare providers do not have a patient-provider relationship. The information we collect will be used to contact you because you have requested that you be contacted.

In addition, Information provided on the website or in any response to you is not and connot be considered medical advice or treatment.

Do you agreee with the terms for Online Appointment?