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 *

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.