Appointment Request Form

If your request is time-sensitive, do not
contact us via email. Please call us
at 402-552-2020.

Please fill in the form below to setup an appointment.
Location*
- 43rd & Dodge
- 135th & California
- 72nd & Giles
- 181st & Q
- Council Bluffs
- Fremont
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Email*
Best Time to be Reached for Confirmation*

: Hours

Minutes
Comments
Email
This field is for validation purposes and should be left unchanged.