Request a Consultation | Associates In Dermatology

Request Appointment Form

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<form-template>
 <fields>
  <field required="true" type="text" name="first-name" placeholder="First Name*" label="First Name"/>
  <field required="true" type="text" name="last-name" placeholder="Last Name*" label="Last Name"/>
  <field required="true" type="text" name="phone-number" placeholder="Phone Number*" label="Phone Number"/>
  <field required="true" type="text" name="email-address" placeholder="Email Address*" label="Email Address"/>
  <field required="true" type="select" name="select-location" label="Select Location">
 <option selected="true" value="">Select Location*</option>
 <option value="Altamonte Springs">Altamonte Springs</option>
 <option value="Apopka">Apopka</option>
 <option value="Celebration">Celebration</option>
 <option value="Clermont">Clermont</option>
 <option value="Davenport">Davenport</option>
 <option value="Dr. Phillips">Dr. Phillips</option>
 <option value="East Orlando">East Orlando</option>
 <option value="Hunters Creek">Hunters Creek</option>
 <option value="Kissimmee">Kissimmee</option>
 <option value="Mount Dora">Mount Dora</option>
 <option value="Ocoee">Ocoee</option>
 <option value="Poinciana">Poinciana</option>
 <option value="Sanford">Sanford</option>
 <option value="St. Cloud">St. Cloud</option>
 <option value="Sumterville">Sumterville</option>
 <option value="No Preference/Not Sure">No Preference/Not Sure</option>
  </field>
  <field type="textarea" name="comments" placeholder="Enter any comments or questions that you may have here..." label="Comments"/>
  <field required="true" type="checkbox-group" name="are-you-interested-in" label="Are you interested in:">
 <option value="Clinical Dermatology">Clinical Dermatology</option>
 <option value="Cosmetic Dermatology">Cosmetic Dermatology</option>
 <option value="Free Cancer Screening">Free Cancer Screening</option>
  </field>
  <field required="true" type="select" name="preferred-call-time" label="When is a good time to call?">
 <option selected="true" value="">Select One*</option>
 <option value="Morning">Morning</option>
 <option value="Afternoon">Afternoon</option>
 <option value="Evening">Evening</option>
  </field>
  <field type="textarea" name="when-are-you-available-for-an-appointment" placeholder="When are you available for an appointment?" label="When are you available for an appointment?"/>
 </fields>
</form-template>

Please fill out the form above to request an appointment at one of our offices. Upon successful submission, a representative will call you within one business day to set your appointment date/time and collect additional information.

If you need immediate assistance please call our office directly at 800.827.7546.

Always call 911 for emergencies.

Last week I had the opportunity to meet you and your fine staff as you worked to clean up a cancerous spot on my face. It turned out to be a lot deeper than anyone including me believed. It took five passes to get to the bottom of it. No one on your team gave up on the effort to get it all. Every time I had to go back for you to search further, everyone was upbeat and positive. Words cannot express how important this was to me as I was getting more and more discourages. Peter, and your magical staff, could not have been more professional nor kind. They each in their own way went out of their way to make me as comfortable as possible while explaining what was going to happen next. Further, I am deeply appreciative of you taking the time to meet with my wonderful wife to explain the process, successes, and challenges.

— Robert OK

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