Online Appointment Request

Online Appointment Request

Need to schedule a medical appointment? This request form lets you select from a variety of treatments while indicating 3 preferred date/time for an appointment. Try out this online patient appointment form! Form Preview
  • Your Information

  • Treatment Info

  • Appointment Info

  • Instructions:  Select up to three (3) preferred appointment dates and times. 

    Please note our business hours:

    MON-FRI: 8:00 AM - 9:00 PM   //   SATURDAY: 9:00 AM - 5:00 PM   //   SUNDAY: 10:00 AM - 6:00 PM   

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  • IMPORTANT:  You will be contacted by a Prolase representative to confirm your final appointment date and time. Your request is not complete without a final confirmation.  

  • Disclaimer:  Although we strive to accommodate your preferred appointment dates and time, we cannot make any guarantees due to a number of conditions, including, but not limited to: business hours of operation, staffing, equipment, availability, and holidays.  Please allow us up to 24-hours to respond to your appointment request. If you are requesting an appointment within the next 24-48 hours, we ask that you please call us to help expedite your appointment request: (818) 507-0909.  

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