Latest News: 
The Polley Clinic is now seeing new patients. 
Please call and fill out your patient
registration online.
Your Subtitle text

Practice News:

Our New Office

Welcome A New Staff Member

....................................
Contact Us:
252.243.0566 Wilson
800.243.0566 Toll Free
252.243.1347 Fax

 Office Hours:
Accepting New Patients
By Appointment Only

Wilson Office
M-Th 8:30am - 5:00pm

Rocky Mount Office
M-Th 8:30am - 5:00pm

Smithfield Office
M-Th 8:30am - 5:00pm

Roanoke Office
M-Th 8:30am - 5:00pm
APPOINTMENT CANCELLATION FORM

This form is necessary to insure that your appointment cancellation and rescheduling is given top priority.  For Cancellation Policies, please review our Payment Policies Page.  Your Cancellation Request will be sent to the Appointment Secretary.
What is the name of the patient for whom the cancellation is being made?:
I am the patient cancelling this appointment.
Yes
Reason for Cancellation:
If you are NOT the patient for whom the cancellation is being made, what is your name?:
What is your relationship to the patient for whom the cancellation is being made?:
What is the DATE of the appointment being cancelled?:
What is the TIME of the appointment being cancelled?:


Please have the Polley Clinic Appointment Secretary contact the following person:
NAME:
HOME PHONE:
WORK PHONE:
CELL PHONE:
Best Time to Reach:

252.243.0566 (Wilson Office)  800.243.0566 (Main Line For Other Offices)  252.243.1347 (Fax)
Wilson, NC    |    Rocky Mount, NC    |    Smithfield, NC    |    Roanoke Rapids, NC

Content copyright . Polley Clinic of Dermatology. All rights reserved.
Website Designed by Brainstorm International