Appointments

To schedule an appointment, please fill out the form below and submit. All fields marked with an * are required.
*Please select one of the following:
New patient Established patient
 
*What kind of appointment do you need?
Annual exam New Pregnancy - Month you are due
Gyn Follow-up OB Follow-up
*Name:
*Mailing address:
*City:
*State:
*Zip:
*Home Phone:
*Daytime Phone:
Email Address:
 
*Do You Have Insurance Coverage? Yes No
(If Yes, the following fields are required)
*Carrier:
*Address for Claims:
*Name of Insured:
*Group Number
*Insured SS#
*Relationship to Insured:
*Phone No. for Insurance Co.
We do not accept Medicaid
 
*Choose your provider
William H. Chambers, M.D. Amanda Harris, M.D.
William E. Brown, M.D. Cole Flanagan M.D.
Nancy S. Lieb, M.D. Nicholas P. Luzietti, M.D.
Mitchell L. Willens, M.D. Melissa Lang, WHCNP
James M. Muse, M.D.  
 
*Date of last Pap Smear
*Date of last menstrual cycle
*Who referred you?
 
When would you like your appointment?
Day of week (first option)
Day of week (second option)
Time of day: A.M. P.M.


 

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