Appointment Request Form

Patient Information

Please complete the form below. We provide free medical care to uninsured and underinsured residents of Pike Township. If you do not live in Pike Township we will be happy to refer you to other facilities. We will get back to you soon to schedule a visit.
Full Name *
Gender *
Phone Number *

Area Code Phone Number
Date of Birth *

Day Month Year
Address *

Street Address

Street Address Line 2

City State / Province
Zip Code *
E-mail Address *
Have you previously visited our facility *

Yes No
Do you currently have medical insurance *

Yes No
Do you agree to receive appointment reminders by text and email? *

Yes No
Appointment Type
Select which appointment type(s) you are requesting *

New Patient Follow up visit Lab results Medication Refill Flu shot/vaccinations Physical Therapy
Date Requested (this is not a guarantee. You will receive a call to confirm your appointment day and time)

Month Day Year
Date
How did you hear about Rophe?

Online Word of Mouth Trustee Office Other
Should be Empty:

Patient Information