Request a Consultation | Associates In Dermatology

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Request Appointment Form

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<form-template>
 <fields>
  <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="Lake Worth">Lake Worth</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>
  </field>
  <field required="true" type="checkbox-group" name="are-you-interested-in" label="Are you interested in:">
 <option value="Clinical Dermatology">Clinical Dermatology</option>
 <option value="Cosmetic Dermatology">Cosmetic Dermatology</option>
  </field>
  <field type="checkbox-group" name="existingpatient" label="Existing Patient?">
 <option selected="true" value="Yes">Yes</option>
 <option value="No">No</option>
  </field>
  <field type="date" name="date" label="Appointment Date"/>
  <field 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>
  </field>
  <field required="true" type="select" name="preferred-call-time" label="When is a good time to call?">
 <option selected="true" value="">Select One*</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 that you may have here..." label="Comments"/>
 </fields>
</form-template>

Upon submission, a representative will contact you during normal business hours to confirm your request.

If you need immediate assistance please call our office directly at 800-827-SKIN (7546).

Always call 911 for emergencies.

I...have been a very proud patient that has referred friends, Business Associates and fellow Rotarians all these past 20 years...Dr Michael’s love of his profession comes out in every conversation, his enthusiasm and up to date knowledge of his industry was very noticeable in his conversations with his Team Members today, while sharing the latest break through Technologies with me...They say “When you go to work because you love your profession, It Shows,“ it sure showed today!

— Sonny B

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