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2. First Name*
3. Last Name*
4. Patient Date of Birth*

   Month/Day/Year

6. Name/relationship of person requesting appointment (if not the patient)
8. Email*
9. Phone Number*

   Please include area code.

11. Requested date of appointment*

    Month/Day/Year

12. Requested appointment time*
14. Appointment type*

    1. Sports Physical
    2. Immunization
    3. Wellness Visit (BP, Cholesterol, Lead testing, HbAlc, B12 injection)
    4. Family Planning (i.e. contraception, pregnancy testing)
    5. Sexual Health/STI Screening/Treatment
    6. Car Seat Training
    7. COVID-19 Testing
    8. Other

    Check all that apply.  If this is a medical emergency, call 911. PLEASE NOTE: Public Health is not a primary care or urgent care facility.  Contact your physician if you are experiencing symptoms or seeking treatment for anything not listed above.

16. Do you have insurance?*

    1. Yes
    2. No
18. If yes, what is the name of your insurance provider?
20. Anything else you would like to add?
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field