South Carolina Internal Medicine

For your convenience, you may fill out the form below to request a new appointment, reschedule or cancel an existing appointment. One of our staff members will call you within 24 hours about your request. Please keep in mind that new appointment times are not guaranteed, but we will try to accommodate your request. We look forward to serving you. If you have an EMERGENCY, please do not use this form, call 911.

* First Name: * Last Name: * Date of Birth: (dd/mm/yy)

* Email: * Daytime Phone:

* Provider I would like to see:

* Appointment Type:

(If you are requesting a new appointment, use this section)

I would like to request a new appointment: Time:

(If you are rescheduling an existing appointment, use this section)

I would like to reschedule an existing appointment. Please cancel my appointment for:

Time:

I would like to reschedule my appointment for:

Time:

* How would you like to be contacted regarding your appointment request? Phone Email

* Reason for Visit:

If you are having trouble with this form, please call our office at 803-749-1111
to speak to one of our patient representatives who will be happy to assist you.