Contact Information

*Name:
Address:
City:
State/Province:
Zip/Postal Code:
*Home Phone:
Daytime Phone:
Fax Number:
*Email:

General Information

Have you been seen by Dr. Reid within the last two years? Yes No

Is this a routine visit (15 minutes) or a compolete physical (1 hour)? Routine Complete Physical

Scheduling

What week would you like? This Week Next Week

What day would you prefer? Monday Tuesday Wednesday Thursday Friday

What time would you prefer? Morning Lunch Hours Afternoon

Which is most important? Week Day Time

Other Information

How should we respond to you? By Email Phone

Additional comments or reqeusts:

* Note that you will be charged $20 for missing an appointment
scheduled by e-mail once you confirm it.