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 you prefer to request a call for an appointment, please click here.



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.