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| Friday, July 04, 2008 |
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Requests are limited to one appointment per request.
The information provided on this screen will be used by our Call Center staff, to assist you in scheduling your appointment. The information will not be placed in your medical record, nor will it be forwarded to any non-related area or entity. When you submit personal information, we offer the use of a secure server. The secure server software (SSL) encrypts all information you input before it is sent to us. Furthermore, all of the patient information we collect is protected against unauthorized access.
Caution: Requests are for NON URGENT appointments only. If you need immediate or more time sensitive assistance, please contact your physician’s office directly.
The Watson Clinic will not, due to issues of patient privacy and Internet security, reply to your request on line. Your request will be followed up by a phone call to you within two business days of its receipt.
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*Required Information
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*Person Submitting Request:
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*Relationship to Patient:
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Patient's Name:
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*Last Name:
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*First Name:
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*Middle Initial:
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*Date of Birth:
(mm/dd/yyyy)
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Watson Clinic Number:
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*Daytime Phone Number:
(000) 000-0000
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*Evening Phone Number:
(000) 000-0000
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Please Select One: Either Provider or Specialty
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Provider:
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OR
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Specialty:
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To help us better anticipate your needs;
Please check the reason below for this non-urgent appointment request.
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*Reason:
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Other Explained:
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Click the boxes below to indicate the days and times that are convenient for you.
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*
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*
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