Appointment Request Form If this is an emergency, do not contact us via email, please reach us by telephone. Please fill in the form below to request an appointment.Location O'Fallon Walmart Maplewood Walmart Reason for AppointmentPlease provide a reason for your appointment. Details are stored securely and not sent by email.Preferred Date & Times*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.Patient Type* New patient Returning patient Please let us know if you are a new or existing patient.Name* First Last Phone*Email* Best Time to be Reached for Confirmation* : Hours Minutes AM PM AM/PM CommentsEmailThis field is for validation purposes and should be left unchanged.