APPT CANCELLATION / RESCHEDULING ?If you need to reschedule or cancel your appointment, please click on the button below !Change / Cancel Request An Appointment Please complete all necessary fields to request an appointment. Step 1 of 2 50% Requesting appointment for(Required) Self Family member Client Requesting appointment for(Required) Consultation NCS/EMG EEG Hearing @amp; Balance Tests Referral Status(Required)Please note that without a referral, appointments are not offered. Please obtain a referral and upload it via the Patient Portal and then contact us for an appointment ! I have a referral Referral has been sent I will seek a referral Urgency of Appointment Request(Required) ASAP Semi-urgent Routine I am willing to pay a deposit to secure an urgent appt spot(Required) Yes No Tele-health(Required) Telehealth preferred Telehealth is optional In-person review needed COVID-19 vaccine status(Required) Fully vaccinated Partially vaccinated Not vaccinated - EXEMPT Not vaccinated - NOT EXEMPT UNKNOWN EXEMPT - have a valid medical exemption * UNKNOWN - if you are requesting this on someone's behalf. HiddenDate DD slash MM slash YYYY TitleMrMrsMissMsMasterDrProfA.ProfReverendName First Last Date of Birth(Required) DD slash MM slash YYYY Date of BirthAge(Required)Age (1-100)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Enter Email Confirm Email Home PhoneMobile(Required)Healthcare Eligibility(Required)MedicareDVA - Gold cardDVA - White cardWorker@amp;#039;s CompThird PartyOverseas Visitor / StudentMedicare/DVA Medicare/DVAWC Claim NoWC Claim NoInjury Date DD slash MM slash YYYY Employer Insurer Referring Doctor(Required) Referring DoctorUsual GP Your Usual GPMessageDo you have any referral or reports to upload ? Yes No Referral/Report UploadAccepted file types: jpg, png, tiff, tif, pdf, rtf, doc, docx, Max. file size: 10 MB.Please upload any documents (e.g. Referrals / Reports) hereCAPTCHA Δ