Secure Internet Services Request an Appointment We aim to respond to all online requests within 48 hours. Your request will be transmitted securely to our office. If you have an emergency, do not use this form – Call 911 or 785-258-2207. Patient's Full Name* Date of Birth* Phone Number* Email Preferred Weekday* Monday Tuesday Wednesday Thursday Friday Preferred Time* Mornings Afternoons No Preference What's the best way to contact you? Phone Email Please describe your symptoms or reasons for requesting an appointment: CAPTCHA