Change Appointment

Please use the form below to submit a request to change or cancel appointments

Patient ID
Patient Name
Patient Email
What changes would you like to make?
- Reschedule my appointment
- Cancel my appointment
- Update appointment date (provider changed it)
- Add or Remove a procedure/consult from my date of service
If the appointment date has already been changed with the provider, please enter the new appointment dates below to update our records.
What is your new appointment date?*
MM slash DD slash YYYY
What is your new appointment time?*

: Hours

Minutes

AM/PM
You must call the provider to reschedule the appointment yourself. Once the appointment is rescheduled, please notify us. Any reschedule must be completed prior to payment deadlines.
Preferred Date Range for new appointment*
Any other notes
Reason for reschedule*
Please explain the reason for the reschedule
If you are trying to cancel only a particular service from your appointment, please call 855-542-6566
Appointment date that needs to be canceled?*
MM slash DD slash YYYY
Cancellation Reason*
Please explain the reason for the cancellation
Would you like to request a refund of payments made?
- Yes. Refund my payments
- No. Hold my funds. I intend to reschedule
- No. I haven't made any payments
Refunds are usually processed within 48 hours.
All changes will be made within 1 business day. You will receive an updated appointment confirmation once an appointment has been modified.
What changes are you requesting?
Phone
This field is for validation purposes and should be left unchanged.

1-972-924-9009