How to reach Dr. Rouff's office
Fields marked with * are required
Patient's Name *: Parent's Name:
New Patient Email Address *:
Existing Patient
Address: City:
State: Zip Code:
Home Phone *: Work Phone:
Preferred Days: Convenient Times:
Morning    Mid-day
Afternoon Any Time
Contact Me By Appointment is For:
Adult Child

How did you hear about
our practice?
How did you find
Dr. Rouff's website?


Terms of Use

By checking this box you agree to the Terms of Use listed here:

Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.

By checking this box you hereby agree to hold Dr. Rouff, its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.