AA Med Clinic Contact Form

Schedule A Discrete Appointment

Name:*

First NameLast Name

Gender*

MaleFemale

Phone Number:*

Area CodePhone Number

E-mail Address:*

Questions / Concerns / Scheduling:*

Please let us know if you have questions or concerns. We will discreetly respond to all questions within a couple of hours.

Please check the box if you would like to schedule an appointment*

Schedule an appointmentAsk question without scheduling

Prefferred Apointment Time

Please select your preferred date and time for the appointment. Please note that we will call you to confirm, but appointment times cannot be guaranteed. We will do our best to accomodate your preferred time.

Appointment Fee

USD$50 Non-Refundable Appointment Fee. First visit is $199. Appointment must be secured by credit card. $50 will be credited towards the $199 fee after your first appoinment.

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country