Request a Consultation | Associates In Dermatology

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="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 type="textarea" name="comments" placeholder="Enter any comments or questions that you may have here..." label="Comments"/>
  <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>
 <option value="Free Cancer Screening">Free Cancer Screening</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="when-are-you-available-for-an-appointment" placeholder="When are you available for an appointment?" label="When are you available for an appointment?"/>
 </fields>
</form-template>

Please fill out the form above to request an appointment at one of our offices. Upon successful submission, a representative will call you within one business day to set your appointment date/time and collect additional information.

If you need immediate assistance please call our office directly at 800.827.7546.

Always call 911 for emergencies.

The best resource for skin care. Always good advice and care. Sarah Fellenz is great in care and service. The OTC cream she recommended is working very well to reduce/remove skin eruptions. Thank you to your wonderful staff.

— James T

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