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Appointment/Cancellation Form

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Please fill out this form if you would like to request, or cancel, a routine appointment. If you have not yet registered, please do so now. (Registration Form)

Office Hours:

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
8AM-8PM8AM-5:30PM8AM-8:30PM8AM-5:30PM8AM-5:30PM10AM-1PMCall

 

Please enter your name: and your email address:

Your Brattleboro Primary Care medical record number, if you know it:

Your date of birth:

I would like to cancel my appointment on (if you would like to reschedule please continue with this form)

 

I would like to make an appointment

           Please indicate who you would like to see:
               

         If unavailable, would you accept another provider?

        Yes         No

Please indicate your preferred appointment time. Do not use this form for urgent or same-day appointments. We cannot guarantee that this time will be available. We will get back to you by email or phone within 2 - 3 days.

Month and Date

Your Address:

City,State,Zip:

Daytime Phone: Evening Phone:

Routine appointments, which will give you enough time to address one or two issues, are scheduled for 15 minutes. If you think you need more time please let our receptionist know. We will get back to you by phone within 2 - 3 days. We cannot guarantee that your preferred time will be available.


Do not use this form for urgent or same-day appointments.

Thank you for choosing Brattleboro Primary Care.