New Patient Appointment Request

New Patient Appointment Request

If you are a new patient that has never had an appointment with Shalom Health Care Center, you can use this form to request a new appointment. If you are an existing patient, please visit https://www.shalomhealthcenter.org/portal to access the Patient Portal to schedule your next appointment.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please briefly describe your medical concern
Which location would you like to visit?

34th Street Primary Care56th Street Primary CareI prefer telehealthWhichever has the first available appointment
Click Submit below to send this request to our team. A member of our staff will contact you shortly to schedule your appointment.
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