A Woman's View Email Center

Appointment Request

Please send the following information and we will try to set an appointment time for you.  Please allow at least 5 working days notice for an appointment.  It is likely that we will be unable to schedule an appointment for you without talking to you first.  Once we have created an appointment, it will be confirmed with you either by telephone or via email. 

If you do not receive a confirming phone call within two days, call (828) 345-0800.  Please note that all items marked with an asterisk (*) are required.

  1. Please provide the following contact information:

    Full Name*  
    Work Phone*  
    Home Phone  
    E-mail*  

  2. In order for us to properly identify you, please provide us with the following:

    Date of Birth*  

  3. What type appointment do you need?*

     

  4. If for a problem, give a brief description of the problem:

  5. Which day is best for you?*

            Monday    Tuesday    Wednesday    Thursday    Friday

  1. Which Month is best for you?*

    January        February        March        April            May            June

    July              August           September October       November   December

     

  2. Which time of day is best for you?*

      Morning    Afternoon

  3. By whom would you like to be seen?*

     

    **Note:  This email is not sent encrypted and as such is not covered by our privacy policy.  Please type "yes" here to verify that you understand that you acknowledge that you are aware of potential loss of privacy and accept responsibility for this communication.  (This email cannot be sent without this acknowledgment.)

A Woman's View, PA
Copyright © 2006 A Woman's View.  All rights reserved.
Revised: June 02, 2008