Appointment Request Form

Please, fill out the form below to request an appointment. We see patients on Monday, Tuesday, Thursday and Friday. We will do our best to accomodate your schedule. If you would prefer to make your appointment in person call us at 920 921 0440, or stop by the office.

Patient Information

New Patient  Established Patient 

Name :  First   M.I.    Last 

Telephone :  920 921 0440    E-mail :  

Date of Birth :  mm/dd/yyyy 


Appointment Request

Month :

Day and Time :

  Morning   Afternoon  Either 

Alternate Day and Time :

  Morning   Afternoon  Either 

Reason for Request : Routine Examination  Emergency  Other 

Additional comments for Dr. Scholz:


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