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Request an Appointment Form

Internet forms should not be used to communicate emergency information!

If you have never seen Dr Moore before, using the New Patient Questionnaire may be a better option for requesting an appointment.


Schedule requests and New Patient forms are processed the following clinic day, and are not a substitute for urgent or emergency care. If you are experiencing an emergency please use local emergency services or dial 911.

This form is used to request a clinic staff person to contact you and make arrangements for an appointment. It is not intended to replace an in-person visit with a medical doctor. The information you submit electronically can only be reviewed during business hours published on this web site. During office hours, you may contact the clinic by telephone at 253-833-7750

As a recipient of information from this web site, and as you submit personal medical information using this form, you are not establishing a doctor/patient relationship with any physician. Clicking the "Submit" button signifies your acknowledgement and agreement to these terms of use.

 

Name:  
Street Address :  
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Email:  
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Please provide the best phone numbers to reach you:   

Home:  
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Referral Code (If Applicable):