Request an Appointment — Joshua K. Burk, MD
Complete this form and the office will call you back to schedule — usually within one business day. Prefer the phone? Call (716) 859-4225. IF THIS IS AN EMERGENCY — sudden severe chest, back, or abdominal pain; a cold, painful leg; signs of stroke — call 911 or go to the nearest emergency department. This form is not monitored for emergencies. Please don't include detailed medical history below — just enough for the office to route your call.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
I am…
*
Please Select
The patient
A family member or caregiver
A referring provider's office
Best time to call
Please Select
Any time
Morning (8–12)
Afternoon (12–5)
Reason for visit
*
Please Select
Aortic aneurysm or dissection
Leg pain, cramping, or poor circulation (PAD)
Non-healing wound or foot ulcer
Carotid artery disease or stroke prevention
Vein problems or blood clot (DVT)
Dialysis access
Second opinion
Referred by my provider
Other or not sure
Referring provider (if any)
Insurance
Anything else?
I agree to be contacted by the office by phone (and email, if provided) about scheduling. I understand this request does not create a physician–patient relationship until I am seen.
*
I agree
Send request
Should be Empty: