Your Name: Relationship to Patient: self doctor family/caregiver
Your Email Address:
Your Primary Phone:
Patient's Name:
Patient's Email Address:
Patient's Primary Phone: home phone work phone cell phone pager fax
Patient's Other Phone: home phone work phone cell phone pager fax
Referring Provider:
Insurance: Medicare Medicaid
Other:

Reason for appointment:

-select Priority Level- Normal Urgent, call 330.572.1011 Emergency, call 911

-select How Soon You Prefer- Urgent Within 2 weeks Next month Within 3 months

My preferred appointment times are:

First Choice:
Day: Mon Tues Wed Thurs Fri
Between: 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM to 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM

Second Choice:
Day: Mon Tues Wed Thurs Fri
Between: 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM to 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM

My preferred location and healthcare provider is:

West Akron: -select provider- No preference, please assign Roswell Dorsett, III, DO Hugh Miller, MD Eugenio Peluso, PhD Jose Rafecas, MD Laura Samson, PsyD Lawrence M. Saltis, MD

-select Procedure Requested- None or Not Sure Concussion Clinic Headache Clinic Trigeminal Neuralgia Neurology Consultation Neurology Follow Up Sleep Consultation Neuropsychological Evaluation/Testing MRI Neurodiagnostic Testing EEG EMG Nerve Conduction Study Infusion Therapy BOTOX Injection Other

Comments: