Waiting List for Dr. Karen Gardner
To be placed on the waiting list, please complete and submit the form. If Dr. Gardner is able to accept your case, she will contact you for scheduling ASAP.
Full Name
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First Name
Last Name
Today's Date
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Month
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Day
Year
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
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Confirmation Email
Cell Phone Number
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Area Code
Phone Number
Whom can I thank for referring you to my practice?
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Who are you placing on the waiting list?
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Please Select
Myself
My child
My spouse
Other
If you are placing yourself on the waiting list, are you pregnant?
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Yes
No
If you answered yes, please indicate your due date. If not, please write N/A
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Please describe with as much detail the reason you would like to make an appointment.
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How long have you been experiencing the above mentioned issue?
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If the patient being placed on the waiting list received an injection ("vaccine") for Covid, please list the dates of injection(s) as well as the Brand Name and any health challenges that have arisen since being injected.
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Office use only
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