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Call Today. 800-827-7546

The staff was very friendly and knowledgeable. I felt at ease dealing with my situation. Very warm and inviting . The staff is Great. Carol, Sandra and Annette keep up the great work!

— Raymond T

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  <field required="true" type="text" name="first-name" placeholder="First Name*" label="First Name"/>
  <field required="true" type="text" name="last-name" placeholder="Last Name*" label="Last Name"/>
  <field required="true" type="text" name="phone-number" placeholder="Phone Number*" label="Phone Number"/>
  <field required="true" type="text" name="email-address" placeholder="Email Address*" label="Email Address"/>
  <field required="true" type="select" name="select-location" label="Select Location">
 <option selected="true" value="">Select Location*</option>
 <option value="Altamonte Springs">Altamonte Springs</option>
 <option value="Apopka">Apopka</option>
 <option value="Celebration">Celebration</option>
 <option value="Clermont">Clermont</option>
 <option value="Davenport">Davenport</option>
 <option value="Dr. Phillips">Dr. Phillips</option>
 <option value="East Orlando">East Orlando</option>
 <option value="Hunters Creek">Hunters Creek</option>
 <option value="Kissimmee">Kissimmee</option>
 <option value="Mount Dora">Mount Dora</option>
 <option value="Ocoee">Ocoee</option>
 <option value="Poinciana">Poinciana</option>
 <option value="Sanford">Sanford</option>
 <option value="St. Cloud">St. Cloud</option>
 <option value="Sumterville">Sumterville</option>
 <option value="No Preference/Not Sure">No Preference/Not Sure</option>
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  <field type="select" name="area-of-interest" label="Select Area of Interest">
 <option selected="true" value="">Select Area of Interest</option>
 <option value="Clinical Dermatology">Clinical Dermatology</option>
 <option value="Cosmetic Dermatology">Cosmetic Dermatology</option>
 <option value="Free Cancer Screening">Free Cancer Screening</option>
  </field>
  <field type="date" name="date" label="Appointment Date"/>
  <field required="true" type="select" name="appointment-time" label="Appointment Time">
 <option selected="true" value="8:00-8:30">8:00-8:30</option>
 <option value="8:30-9:00">8:30-9:00</option>
 <option value="9:00-9:30">9:00-9:30</option>
 <option value="9:30-10:00">9:30-10:00</option>
 <option value="10:00-10:30">10:00-10:30</option>
 <option value="10:30-11:00">10:30-11:00</option>
 <option value="11:00-11:30">11:00-11:30</option>
 <option value="11:30-12:00">11:30-12:00</option>
 <option value="1:00-1:30">1:00-1:30</option>
 <option value="1:30-2:00">1:30-2:00</option>
 <option value="2:00-2:30">2:00-2:30</option>
 <option value="2:30-3:00">2:30-3:00</option>
 <option value="3:00-3:30">3:00-3:30</option>
 <option value="3:30-4:00">3:30-4:00</option>
 <option value="4:00-4:30">4:00-4:30</option>
 <option value="4:30-5:00">4:30-5:00</option>
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  <field required="true" type="select" name="preferred-call-time" label="When is a good time to call?">
 <option selected="true" value="">When is a good time to call?*</option>
 <option value="Morning">Morning</option>
 <option value="Afternoon">Afternoon</option>
 <option value="Evening">Evening</option>
  </field>
  <field type="textarea" name="comments" placeholder="Enter any comments or questions here..." label="Comments"/>
 </fields>
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