Appointment Request

If this is a medical emergency, call 911 or please go to the nearest emergency room

  • This form is only monitored during normal business hours.
  • Normal business hours are Monday through Friday, 8:00 a.m. - 4:30 p.m.
  • You will be contacted within one business day of leaving your request.
  • If you have any questions regarding your submission please call (859) 258-4362.

Thank you for using our online appointment request option.


If other please list your name and relationship in the box below.









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Please schedule my appointment for












Are you looking for a specialist, if so, what type?




Primary Insurance


PRIMARY INSURANCE: Please enter information as it reads on the front of your insurance card. Use the complete insurance plan name. If you do not have insurance, please enter "none" or "N/A" in the required fields.









Secondary Insurance


SECONDARY INSURANCE: Please enter information as it reads on the front of your insurance card. Use the complete insurance plan name. If you do not have secondary insurance, please enter "none" or "N/A" in the required fields.