Request an Appointment

Tell us how to reach you and when works best. The Hope Addiction Medicine team will contact you to confirm your visit.

Important: Please don't include personal health information in this form. Call (843) 737-0312 and we will take those details by phone.

Fields marked required are needed so we can reach you.

Full name

Phone number Include your area code, for example (843) 555-0100.

Email address

Patient status

Preferred contact method

Preferred time

What can we help with? (optional) A sentence or two is plenty. Please leave out sensitive medical details; we will go over those with you directly.

This form is for scheduling only and is not monitored for emergencies. If this is a medical emergency, call 911.