Request Appointment

If you would like to request an appointment at our hospital, please fill out and submit the form below, or call us at 816-880-6650. Please note that this is only a request, someone from our office will contact you shortly to confirm a date and time for your appointment. If your matter is URGENT, or you feel you are experiencing an EMERGENCY, please call us immediately at 816-880-6650 and DO NOT use the form below.

Your Name*

Your Email*

Your Phone*

Request Date*

Requested Time of Day*
Morning (8-12)Afternoon (12-4)Evening (4-6)

Reason for Appointment: