Request Appointment

To help us assess your request, please fill out the form below. Our team will review your information and be in touch to offer you an appointment.

Appointment Request

It's important to provide accurate information to allow us to contact you to arrange an appointment.

First Name

Last Name

Birth Date

Contact number

Billing Information

Dr Dan Fick is unable to accept new DVA patient referrals

This information will be used to help offer you appropriate help in a timely way.

Reason I’m requesting an appointment

Recent Imaging

I've had scans and/or imaging done recently

Scan Location

Referral (If you are unable to provide a referral now, we may request one at any stage of your journey.)

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