Request An Appointment

This online form is used by the Community Health Center staff. If you need to meet with any other division of the Health Department, please call the division using the Phone Numbers on this website.

The information you supply is stored in a secure database. Only the Community Health Center staff will see it.

Appointment Form

Please fill out the form to request an appointment. 

 

RadDatePicker
Open the calendar popup.

Please fill in the following fields with patient information.

Type in the date of the patient's birth. You can use the calendar date selector. Click the calendar icon below next to the date of birth field, then click the month
and year to quickly select the birth month and year.

 

RadDatePicker
Open the calendar popup.

Enter your name as Requesting Individual if you are NOT the patient.

Once you click the submit button, your information will be stored on our secure server and not sent over the Internet in an e-mail. Our office staff will reply to your appointment request as soon as possible.

 

* Required