Make an appointment

We suggest that if possible, you make your appointment at the same time you make arrangements for your procedure.

Payment is required upon completion on the day of service by cash or personal check made out to Christine Thomson. We also accept all major credit cards, with a 5% service charge.

The Discreet Chaperone is a medical escort service. The chaperones are not medical professionals, but experienced and caring companions.

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Patient Name:*

Date of Birth:*

Address:*

Street Address City State / Province / Region ZIP / Postal Code Country

Email:*

Telephone:*

Pick up Address:*

Destination:*

Date of Procedure:*

Time of Procedure:*

:

Type of Procedure:*

Office Contact:*

Physican's Name:*

Email:*

Telephone:*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Time Chaperone is expected at the facility:*

:

Number of Chaperone hours requested:*

Name

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Fully Insured & Bonded

Doctor Recommended

Confidential