ONLINE APPOINTMENT REQUEST FORM If you are a current patient, or if you wish to become a patient, we want to hear from you. Please complete this form and a member of the scheduling team will call you to schedule an appointment within (2) business days. For faster service, our schedulers are available to help you from 8:00 am to 5:00 pm M-F at (828) 258-8681, option 1. Thank you for choosing The Family Health Centers. OK Question Title * 1. Please tell us your name: First M.I. Last OK Question Title * 2. Please tell us your date of birth: Month Date Year OK Question Title * 3. Are you an established patient, or a new patient requesting a first appointment with The Family Health Centers? Established patient, requesting an appointment New patient, requesting first appointment OK Question Title * 4. What type of health insurance do you have? Medicare Medicaid I don't have health insurance. I will pay for services out-of-pocket. I have commercial health insurance. If you have commercial insurance, please specify the insurance carrier, e.g. Blue Cross, Blue Shield. OK Question Title * 5. Please share your preferred telephone number, including area code, so that we may call you to schedule an appointment: OK Question Title * 6. How did you hear about The Family Health Centers? Family or Friend Another Doctor or Specialist Employer Google Search Social Media Print Advertisement Yellow or White Pages Event, e.g. Health Fair or Job Fair Brochure I am a current patient Other (please specify) OK CLICK HERE TO SUBMIT. THANK YOU! WE WILL CONTACT YOU SOON.