Step 1 of 3 - Patient Information 33% Name* First Last Email* Phone*Patient Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Appointment Request Type*Adult UrologyPediatric UrologyGender*Select an OptionMaleFemaleOtherReason for AppointmentResponsible Party Name*Date of Birth - Responsible Party* Date Format: MM slash DD slash YYYY Responsible Party’s Relation to Patient*MomDadGuardianPrimary Care DoctorType of Insurance*ID or Contract Number*Group NumberSubscriber Name*Subscriber Date of Birth* Date Format: MM slash DD slash YYYY Choose Your Doctor*No Preference / New PatientDr. AnemaDr. BarberDr. DeHaanDr. RoelofDr. ThompsonDr. WeatherlyDr. WiseChoose Your Doctor*No Preference / New PatientDr. BarberDr. RoelofDr. WeatherlyLocation Options*AlleganBig RapidsDowntownGreenvilleIoniaWyomingLocation Options*DowntownWyomingLocation Options for Dr. Anema*AlleganDowntownWyomingLocation Options for Dr. DeHaan*DowntownWyomingIoniaLocation Options for Dr. Curry*GreenvilleBig RapidsDowntownLocation Options for Dr. Thompson*WyomingLocation Options for Dr. Wise*DowntownBig RapidsLocation Options for Dr. Barber*Downtown OnlyLocation Options for Dr. Roelof*Downtown OnlyLocation Options for Dr. Weatherly*DowntownWyomingAppointment PreferenceMorningAfternoonEither is FineCAPTCHA