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Please provide the name of the patient that you are requesting the appointment for.  If this is a child, please provide parent or guardian name in the comment box.  
If you have insurance you would like to use for your visit, please provide that information in the comment box below.  We need the insurance name, primary member name, ID number, as well as a good contact number for the patient.  If we are not an in-network provider, or if you are not eligible for services, we will contact you at the number provided.  Also, if you have an HMO, you will need to contact your primary care physician for a referral before your appointment date.  Thank you.

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Please note that the date and time you requested may not be available. We will contact you to confirm your actual appointment details.