Appointment Request - GI Janel Consult

GI Janel Anywhere Consultation Request
This form submits and stores information, including potential protected health information (PHI), electronically.

You will be contacted via email to schedule your appointment. Email is not considered a secure form of communication.

Click here to read more on our policies for your protected health information.
Consultations with Dr Kathleen Janel via GI Janel Anywhere does NOT establish a Doctor/Patient Relationship.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number

Area CodePhone Number
Preferred Consultation Date or Dates
Preferred Appointment Times - All times listed are Pacific Timezone
New or Existing Consult
Main Consultation Concern
Anything else we need to know?
Should be Empty:

GI Janel Anywhere Consultation Request