Fields with an asterisk (*) are required.
Child's Date of Birth*
Reason for Appointment/Symptoms
Your First Name*
Your Last Name*
Your Email Address*
Your Phone Number*
Our staff will call you on the first business day after you submit this form. Call Center hours are 8:00 am to 5:00 pm, Monday - Friday. Thank you!
© 2016 Brenner | Site Policies & Statements
The information on this Website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified healthcare provider. If you have a medical problem or a health-related question, consult your physician or call Health On-Call at 336-716-2255 or 1-800-446-2255.