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Online Appointment Booking


To book an appointment online, please complete and submit the form below. “Online Appointments” must be made 24 hours in prior to the date you prefer to come into our Clinic. We will contact you via email within 24 hours upon your submission. If you need to see us sooner than 24 hours, please call us at 477.2873 to book an appointment over the telephone.


We accept walk-ins, but please note, that our physician is off at 6pm. Please bring your photo ID, and if you have health insurance please bring your card. If you are bringing someone else’s child you must have written authorization from parent or guardian.



*Required Fields
     
*REASON FOR VISIT:
     
PATIENT INFORMATION ONLY
 
*NAME: *DOB:
*CONTACT # (H): (C) *EMAIL:
(W):
ADDRESS:
   

*LASER PATIENTS ONLY: WOULD YOU LIKE A FOLLOW UP PHONE CALL?   Yes  No

     
Your Preferred Appointment

Date*


Time*

 HOURS OF OPERATIONS:
Monday - Sat 8:30am - 8pm
Sunday 11am - 2pm
   
 
PATIENT MEDICAL INFORMATION
 
* PAST MEDICAL HISTORY:  
* PAST SURGERIES:  
* CURRENT MEDICATION:  
* ALLERGIES TO MEDICATIONS:  
     
*DO YOU DRINK ALCOHOL? Yes  No
*DO YOU SMOKE?    Yes  No
     

I, the undersigned, authorize medical and/or surgical treatment as recommended by the physician/physician assistant or Nurse Practitioner and whomever she may designate to administer such treatments as necessary. I also consent to the administration of anesthetics that may be necessary. I certify that no guarantee or assurance has been made as to the results that may be obtained. I realize I am liable for all charges incurred.

Any dispute between the patient and ExpressCare, or its physicians and staff, including claims by patient of negligence of medical malpractice, shall be subject to binding arbitration pursuant to 7 GCA Chapter 42 Civil Arbitration. Jury trial is waived.

     
I HAVE HAD A CHANCE TO READ AND REVIEW THE CLINIC’S PRIVACY POLICY. YOU MUST CHECK THE BOX IN ORDER TO MAKE AN APPOINTMENT ONLINE.
     
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*We trace I.P. Addresses to prevent online fraud.

    
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