Enter Patient Information
Desired Time Slot
*
2:30pm
4:00pm
4:30pm
6:00pm
6:30pm
9:30am
10:00am
10:30am
11:00am
11:30am
12:00pm
12:30pm
1:00pm
2:00pm
2:30pm
3:30pm
4:00pm
4:30pm
5:00pm
5:30pm
6:00pm
6:30pm
First Name
*
Last Name
*
Date of Birth
*
Do you have your order in hand?
Yes
No
Who is the ordering doctor and/or clinic?
Cell Phone Number
Text message confirmation will be sent.
Reserve Time