Appointment Request

BFG Medical Clinic can be reached during normal business hours by phone. If you have a medical emergency, please dial 911.

If this is an emergency, do not contact us via email, please use our emergency contact information.

Appointment Request Form

Firstname: *

Initials *

Phone number *

Email Address *

Date *

(Example: 04/23/2017 mm/dd/yyyy)

Time

Morning

Afternoon

Evening

Subject *

Preferred Response *

Email

Telephone

We will like to know if you would prefer to be contacted by e-mail or phone

TERMS AND CONDITIONS *

To use the electronic messaging system I am aware that my personal details may not be fully secure. I hereby take full responsibility for sending this message and completely absolve BFG Medical Clinic and all it's affiliated parties of all liabilities and responsibilities.

If you are human, leave this field blank.