Online Appointment Request Form

(Fields noted by * are required fields)

First Name*
Last Name*
Email*
Phone*
Street Address
Street Address 2
City:
State/Province:
Postal Code:
Best time to call:

Comments**

** Please note that this is not a secure email transmission site. The Sinus Institute at CEI is committed to protecting your privacy as per the federal HIPPAA guidelines. Do not transmit information of a private or personal nature. If you are uncomfortable with this email contact form, contact us directly via phone or fax.

If you are a current patients and have a question for your provider, please use our secure system here. NOTE: this is ONLY for current patient of CEI.