Medical Appointment Request Form

Please complete this form to request a medical appointment with Dr. Cori Skarda. Her assistant will reach out to you within 48-72 business hours after completing this request form to schedule your appointment. Dr. Skarda specializes in both mental health and weight management services.

Limitations: Appointments are available for adults (age 18 and older). Appointments for children are not available at this time. Please keep in mind that she does not prescribe controlled substances and does not treat bipolar disorder or schizophrenia.

Patient First name

Patient Last name

Patient Birthday

Patient Phone

Patient Email

How do you Prefer to be Contacted?

Phone

In 2-3 sentences, please explain your reason for requesting an appointment with Dr. Skarda:

EAST TEXAS COUNSELING GROUP

LONGVIEW: 405 MAGRILL ST | MARSHALL: 221 EAST END BLVD SUITE B

Medical Appointment Request Form

Phone: 903.502.0490 - INFO@ETXCOUNSELING.COM - Fax: 903.502.9575

East Texas Counseling Group, LLC | All Rights Reserved | Phone: 903.502.0490

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