Waiting List for Dr. Karen Gardner
To be placed on the waiting list, please complete and submit the form.
Full Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
Confirmation Email
Cell Phone Number
*
-
Area Code
Phone Number
Whom can I thank for referring you to my practice?
*
Who are you placing on the waiting list?
*
Please Select
Myself
My child
My spouse
Other
If you are placing yourself on the waiting list, are you pregnant?
*
Yes
No
If you answered yes, please indicate your due date. If not, please write N/A
*
Please describe with as much detail the reason you would like to make an appointment.
*
If the patient being placed onthe waiting list received an injection ("vaccine") for Covid, please list the dates of injection as well as the Brand Name *
*
Office use only
Submit
Should be Empty: