Appointment Request Form

Appointment Request Form

For questions about your appointment, please contact us at 203-797-8990.

Note: This is not to be used for emergencies. In case of an emergency, please call us
at 203.797.8990

*Denotes Required field.

Patient Information
First Name: *
Middle Initial
Last Name: *
City/State:
Zip Code:
E-Mail *
Date of Birth: *
Date of Birth: *	mm dd yyyy
Daytime Phone: *	- - ext. Extension not required
Best time to contact you *

Appointment Information
Patient Status:
Preferred Day:
Preferred Time:
Preferred Location:	Not all days available in all locations
Appointment Type:*
Provider:*	Click to view provider bios

Other Information
What insurance do you have?:*	If your insurance requires a referral for a specialist visit, you must obtain one from your primary care physician.

Please indicate any additional information or special requests:
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Dr. Goldberg Dr. Federman Dr. Zirn Dr. Perez Dr. Lipper Dr. Gohara Dr. McFerren Michael S. Thibault, PA-C

Dermatologists Dr. Barry S. Goldberg, Dr. Grace L. Federman, Dr. Jonathan R. Zirn, Dr. Maritza I. Perez, Dr. Graeme M. Lipper, Dr. Mona A. Gohara, Dr. Marcus A. McFerren and Michael S. Thibault, PA-C of Advanced DermCare, serving Danbury, Newtown CT, Bethel, New Milford, Ridgefield, Monroe CT, Hawleyville, Brewster NY, Trumbull, Brookfield and Redding CT, and the surrounding area.

Danbury Location: 25 Tamarack Avenue | Danbury, CT 06811 | Tel: 203-797-8990

Southbury Location: 760 Main Street, S. C-2 | Southbury, CT 06488 | Tel: 203-267-6465

Ridgefield Location: 38 B Grove Street | Ridgefield, CT 06877 | 203-438-5920

www.advanced-dermcare.com