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 CodePhone Number
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code*
E-mail Address*
Have you previously visited our facility*

YesNo
Do you currently have medical insurance*

YesNo
Do you agree to receive appointment reminders by text and email?*

YesNo
Appointment Type
Select which appointment type(s) you are requesting*

New PatientFollow up visitLab resultsMedication RefillFlu shot/vaccinationsPhysical Therapy
Date Requested (this is not a guarantee. You will receive a call to confirm your appointment day and time)

MonthDayYear
Date
How did you hear about Rophe?

OnlineWord of MouthTrustee OfficeOtherOther
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Patient Information