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Book an appointment

Great doctor if you need your family member to get effective immediate assistance, emergency treatment or a simple consultation.

Appointment Form

Patient Information

First name *

Last name *

Date of birth *

Gender (optional)

Phone number *

Email address *

Street address (optional)

City (optional)

State (optional)

Type of appointment *

Preferred date (optional)

Preferred time (optional)

Reason for visit / Primary concern *

Mobility / home environment notes (optional)

Best way to contact *

Emergency contact (optional)

Consents & Notices

I authorize Kunect Healthcare and its staff to contact me regarding this appointment and understand my information will be used in accordance with the Privacy Policy. *

I consent to receive telehealth services if offered and understand the technology and privacy implications.

I consent to receive appointment reminders and communications by SMS. Message/data rates may apply.

How did you hear about us? (optional)

Required: First name, Last name, Date of birth, Phone number, Email, Type of appointment, Reason for visit, Best way to contact, HIPAA/Contact consent.

Book an appointment

Appointment Form

Patient Information

Consents & Notices