Existing Patient Appointment Request

Please correct the errors described below.

By completing this form, I confirm that I am NOT in an emergency situation, not suicidal and not in a state of danger to myself or others.

If you or someone you know is suicidal, get help immediately via 911 or the nearest emergency room, the Suicide and Crisis Lifeline by calling or texting 988 or the Crisis Text Line by texting “HOME” to 741741.

Requests are NOT monitored after business hours or on weekends.

You will be charged $50 if you do not cancel by the end of the business day prior to your appointment date.

I understand that if I require a refill prior to my appointment that I must fill out the Medication Refill Request form.

As often as possible patients should follow up with their routine provider but if you have an URGENT need and require a medication change in between appointments, we will accommodate you with the NEXT AVAILABLE provider as quickly as possible.

Full name

Date of birth

If you are completing this form on behalf of someone else, please provide your name and relation.

Email address

Phone Number

I am an EXISTING patient and my Provider is:

Whitney Erickson, PMHNP Lisa Williams, APN Jacqueline Sharp, PMHNP Laurie Miller, APN Justin McAdoo, DNP, APRN, CRNA, PMHNP-BC Beth Grant, MS, LPC, MHSP

I need to

schedule a new appointment . reschedule an existing appointment. cancel an existing appointment. verify an appointment date or time.

Preferred date and time

Based on availability. We are closed on nights and weekends.

Comments

I understand that sending multiple request, including using multiple methods of contact, will delay the office's ability to get back with me.

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