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The Canandaigua Medical Group
Request for Appointment to See Provider

Please fill out the form below to request an appointment with one of our providers. This form is to make appointments 2 weeks or more in the future. Please call your doctor's office if you need an appointment within 2 weeks.

Do not use this form if you need an urgent appointment or one within the next 2 weeks.

In case of emergency, call your doctor's office or 911.

If you do not receive an appointment letter within the next week, please call your physician's direct number or call 393-2888.

The information with the * is required.

New Patient
Established Patient

First Name:*

Last Name:*

Birthdate:*
Please use calendar icon

Primary Provider Name:*

Telephone:* (days - 8am to 5pm)

Area code Number

Telephone (other):

Email Address:*

Please Confirm Your Email Address:*

Street address:*

Street address:

City:*

State:*

Zip:*

What is your Insurance Name:*

Insurance ID Number:*

Primary name on insurance card:*

Appointment Information

With whom do you want an appointment?

Request:

Make an Appointment -

Date - 1st choice Please use the calendar icon
Date - 2nd choice Please use the calendar icon

We will make every attempt possible to honor your request, but if these dates are not available please select from these choices.

2 weeks to 1 month from today
1 to 2 months from today
2 to 3 months from today
3 to 6 months

Cancel an Appointment - Date?
Please use the calendar icon

Reschedule an Appointment - Original Date?
Please use the calendar icon

Preferred Date/Time

Any Day/Time

These Days/Times (check all that apply)

	8-10 AM	10-12 AM	1-3 PM	3-5 PM
Monday
Tuesday
Wednesday
Thursday
Friday

Reason for Appointment

Briefly describe other reason:

Have you been seen before for this issue?

Yes
No

The information with the * is required.

You will receive a detailed confirmation by US postal service in the next few days. If you have not received this letter within one week, please call the office at 585-393-2888.

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Last update 01/29/2008.

The Canandaigua Medical Group Request for Appointment to See Provider

The Canandaigua Medical Group
Request for Appointment to See Provider