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.

PLEASE NOTE: THIS FORM IS FOR NON-ACUTE APPOINTMENTS ONLY. IF YOUR ILLNESS REQUIRES IMMEDIATE ATTENTION, PLEASE CALL US.

Question Title

* 1. Please tell us your name:

First

M.I.

Last

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* 2. Please tell us your date of birth:

Month

Date

Year

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* 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

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* 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.

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* 5. Please share your preferred telephone number, including area code, so that we may call you to schedule an appointment:

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* 6. How did you hear about The Family Health Centers?

Family or Friend

Another Doctor or Specialist

Employer

Google Search

Insurance Company

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)