On-Line Cancel & Reschedule Request

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5969 E Broad St.
Columbus, OH
43213-1546
Phone (614) 864-6010
Toll Free (866) 877-1757
Fax (614) 864-0306

Request to Cancel and Reschedule Appointment
Please complete all of the following fields to ensure that your appointment request is complete.

THIS CANCEL AND RESCHEDULE APPOINTMENT FORM WAS CREATED TO REDUCE THE NUMBER OF INCOMING PHONE CALLS SO THAT WE CAN BETTER SERVE OUR PATIENTS. PLEASE DO NOT CALL TO SEE IF THE EMAIL WENT THROUGH.

We will contact you to confirm the appointment once we have processed the email and canceled or rescheduled the appointment for you. For life threatening emergencies please do not use this email form.

Please Note: We ask that you complete this form the at least 24 hours in advance should you need to reschedule or cancel your appointment. Failure to do so may result in a $25.00 no show fee.

I would like to:
Cancel my current appointment (complete the first section only)
Cancel and reschedule my current appointment (complete both sections)

Physician name

If your primary care physician is not available you may see one of our Certified Nurse Practitioner

Patient Name

Last four digits of patients Social Security Number

E-mail address

Re-enter E-mail address

Date of appointment you are canceling

Time
MM/DD/YYYY

If you are rescheduling your appointment please complete the section below.
(Not required if you are only canceling your appointment)

Reason for Appointment

First Choice

Between and
MM/DD/YYYY

Second Choice

Between and
MM/DD/YYYY

Scheduling or canceling an appointment online - Our policy is to complete your appointment request within 1 hour of your request during regular business hours. We will contact you and confirm an appointment within the time frames you provided. If there are no appointments available we will offer other times outside your window.


	Canyon Medical Center

J. Kelley Brennan, M.D.
Stephen Canowitz, M.D.
John DiPietra, M.D.
Mark Hackman, M.D.
Robert Hershfield, M.D.
Sarah Jonaus, M.D.
Stephen Shell, M.D.
Ethan Shoaps, M.D.
Boris Valdman, M.D.
Timothy Nuss, C.N.P.
Susan Rankin, C.N.P..

Office Hours:
Monday : 8am to 5pm
Tuesday: 8am to 5pm
Wednesday: 8am to 5pm
Thursday: 8am to 5pm
Friday: 8am to 5pm
We offer appointments during the times listed above.

Laboratory Hours:
Monday: 7am to 4:30pm
Tuesday: 7am to 4:30pm
Wednesday: 7am to 4:30pm
Thursday: 7am to 4:30pm
Friday: 7am to 4:30pm
The Laboratory is first come, first serve.