Follow-Up Appointment Request

Request a follow-up appointment (existing patients only).

Important: This form is for patients already in our practice. If you are a new patient, please complete New Patient Intake instead.

Your first name *

Your last name *

Phone *

Patient first name *

Patient last name *

Patient date of birth *

Your provider name

We will try our best to match your preferred times. Your final appointment date and time will be confirmed via text or email.

Appointment Preference 1 (First Choice)

Preferred day of the week *

Any Weekday Monday Tuesday Wednesday Thursday Friday

Preferred 2-hour time block * Any Time 9:00 AM – 4:30 PM

Morning 9:00 AM – 11:00 AM Midday 11:00 AM – 1:00 PM Early Afternoon 1:00 PM – 3:00 PM Late Afternoon 3:00 PM – 4:30 PM

Late afternoon is a 1.5-hour block to fit clinic hours (3:00 PM – 4:30 PM).

Alternative day of the week *

Any Weekday Monday Tuesday Wednesday Thursday Friday

Alternative 2-hour time block * Any Time 9:00 AM – 4:30 PM

Morning 9:00 AM – 11:00 AM Midday 11:00 AM – 1:00 PM Early Afternoon 1:00 PM – 3:00 PM Late Afternoon 3:00 PM – 4:30 PM

Additional message

I consent to be contacted about this request. *

Harmonious Mind LLC • 5189 W. Woodmill Dr, Suite 30, Wilmington, DE 19808 • (302) 633-6001 • SMS: (302) 565-4818 • Fax: (302) 295-6289 • Support@HarmoniousMind.com • Save to Contacts