Become Our Patient

To schedule an appointment, please call our office at 419-287-2201 or toll free; 1-866-804-7392. To request an appointment online complete, and submit the automated form below.


You can obtain all of the pre-registration forms online by simply clicking the forms icon below. Please complete the forms, and bring them, and your insurance card(s), with you to your visit. Completing the forms prior to your visit will help to speed up the registration process, and get you in to see Dr. Krukemyer faster!

forms

Please note: if you are using a dial-up Internet connection, It may take a few minutes to load the forms. You may need Adobe Acrobat Reader to view the forms. You can get it for free by clicking on the icon below.
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Make an Appointment

Your Name*
Subject*
E-mail address
Address*
Telephone Number*
Are you a current patient?*
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Would you like to make an appointment?*
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Preferred Date
Preferred Time
Insurance*
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If Yes, provide company name
Birth Date*
Enter date
How did you learn about us?*
What are your hearing concerns*
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