You may use the form below to send a secure online request to our practice.  Our appointment request form allows you to request a specific provider, specific location and a general time and day of the week that best fits your schedule.  We will do our best to match your request with an available time slot in our practice management schedule.  Once we have identified an opening, we will contact you to confirm your appointment.

 

Appointment Scheduling Request Form Parent's Name: Child's Name: Email Address: Home Phone: Work Phone: Cell Phone: Date of Birth: Address: City: State: Zip Code:               Contact Method: Home phone Work phone Cell phone           Schedule Type Schedule    Reschedule       Preferred Day: Mon.  Tue.  Wed.  Thu.  Fri.  Preferred Time: Morning(AM)      Afternoon(PM)      (9 AM - 10:45 AM)   (1:30 PM - 3:45 PM)     Secondary Day: Mon.  Tue.  Wed.  Thu.  Fri.  Secondary Time: Morning(AM)     Afternoon(PM)      (9 AM - 10:45 AM)       (1:30 PM - 3:45 PM)     Appointment Type: Annual New Pregnancy Other (Describe) If "Other", Please Describe: Choose Physician: -- Select Provider -- Richard Henegan, M.D. Laurel Dickason, M.D. Julia Richards, M.D. Debra Johnson, M.D. Kym Waker, M.D. Kendra Hansen, PA-C