Appointment Request Form

Name                      

Email                        

Telephone Number   

Provider        Dr. Mark Arvind Dr. Wayne Beauford Dr. Sam Bickley Dr. Candace Bradley Dr. Surya Challa Dr. Thomas Jarrett Dr. Steven McDonald Dr. Lenin Peters Dr. Julius Torelli Mr. Don Bulla RPH, PA-C Mr. Mike Duran PA-C Mrs. Suzann Hedgecock PA-C Mrs. Greta OBuch PA-C Mrs. Amanda Taylor PA-C Mr. Patrick Watterson PA-C, ATC-L Mrs. Cindy Vertefeuille ANP-C

Type of Appointment New Patient Complete Physical Established Patient Follow-up Pap Smear Consultation

Preferred Day            Monday Tuesday Wednesday Thursday Friday

Preferred Time           8am-10am 10am-12pm 12pm-2pm 2pm-5pm 5pm-7pm

You will be contacted by a member of our staff to confirm your appointment date and time.

Refill Request Form

Name                      

Email                        

Telephone Number   

Provider        Dr. Mark Arvind Dr. Wayne Beauford Dr. Sam Bickley Dr. Candace Bradley Dr. Surya Challa Dr. Thomas Jarrett Dr. Steven McDonald Dr. Lenin Peters Dr. Julius Torelli Mr. Don Bulla RPH, PA-C Mr. Mike Duran PA-C Mrs. Suzann Hedgecock PA-C Mrs. Greta OBuch PA-C Mrs. Amanda Taylor PA-C Mr. Patrick Watterson PA-C, ATC-L Mrs. Cindy Vertefeuille ANP-C

Medication   

Strength       

Dosing          Once a day Twice a Day Three times a day Four times a day Every 6 hours as needed Each Day at bedtime  

Quantity       

Pharmacy           

Pharmacy Phone #        

Please allow 48 hrs for processing.