• Online Patient Appointment & Consent Form

  • Please note if you have any type of insurance (Medicaid, Medicare, ObamaCare or etc) or are finiacially capable to afford to see a doctor then please do not proceed to request an appointment.

    This service is ONLY for those who do not have insurance and are not financially able to afford basic health services.

    Our EHR system checks if you have insurance and if we discover that you do have insurance, then you will not be given an appointment and any existing appointments will be cancelled.

  • Please note, if you are requesting an appointment with the Gynecologist for a Well Woman Visit, the earliest appointment available is in June 2021.

  •  /  /
    Pick a Date
  •  -
  •  -
  • Spouse/Significant other Information

  •  -
  • Emergency Contact Person

  •  -
  • Medical History:

  • Family History:

  •  /  /
    Pick a Date
  • Should be Empty: