Please notes that all fields marked with an "*" are required to successfully submit the request form. Thank you!

Page Removal

On Dec. 1^st, 2026 this form will no longer be available as we have moved our appointment request system over to MyChart. To request an appointment within the MyChart system, please visit providers.smh.com and search by specialty, condition or provider.

Request an Appointment

First Name*

Last Name*

Phone Number*

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Email*

Gender*

Select a specialty*

Appointment reason, question or comment*

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