2020 Peachtree Rd, NW
Atlanta, GA 30309
Phone: 404-355-1144
Fax: 404-355-6980
Home
About Us
Conditions Treated
Treatment Options
Provider Profiles
Make an Appointment
New Patient Forms
Patient Education
Testimonials
Biofeedback
A Way of Life
Give to Shepherd
Location
Contact Us
Appointment Request
This service is ONLY FOR NON-URGENT appointment requests. If the patient has an urgent request, please call 911.
* Required Fields
Appointment Service Options:*
-- Select a Service Option --
Request an Appointment
Cancel an Appointment and Reschedule
Cancel an Appointment Only
Request Provider
(optional)
Dr. Bert Blackwell
Dr. Erik Shaw
Dr. Urzula Klich, Ph. D.
Request for Information
The Requestor may be the patient's relative, caregiver or friend.
First Name:
*
Last Name:
*
Patient Information
Same as Above
First Name:
*
Last Name:
*
Patient Phone Numbers:
SPI will use these patient numbers to confirm the appointment request:
Patient preferred number:
*
Patient preferred alternate number:
Patient preferred email address:
Patient Type: *
-- Select Patient Type --
New Patient
Returning Patient
Requested Date:
First Available
Or
Preferred Date
Preferred Time(s):
Any Time
Early AM
Late AM
Early PM
Late PM
Patient Health Insurance *
-- Select Health Insurance --
Aetna
Blue Cross/Blue Shield of GA
Blue Choice (BC/BS of GA)
CIGNA Healthcare
Kaiser
Coventry Health Care
Great West Health Care-One Health
Humana Health Plan
Kaiser Permanente Health Plan
Medicare
United Health Care
Not Listed (enter in box below)
None
Other Insurance:
Comments:
characters left.