Booking Form Specialist

A referral from a primary care provider is required for this clinic.

Please complete the below form. Shortly after receiving your request, one of our Patient Care coordinators will contact you to discuss your options for booking a primary care appointment in order to get a referral.

All your information is kept strictly confidential and 100% secure. For life-threatening emergencies call 911. If you are suffering an acute mental health crisis call 1-833-456-4566.
Is this appointment for you or for your dependent?*

This appointment is for myselfThis appointment is for my dependent
Are you a returning patient?*

YesNo
Is your dependent a returning patient?*

YesNo
Patient Information
Patient name*

First NameLast Name
Pronouns
Please select "Other" to provide the patient's preferred pronouns
Please enter the preferred pronouns
Date of birth*

MonthDayYear
Date
Sex assigned at birth*
Gender identity
Please select "Other" to provide the patient's preferred gender identity
Please enter the preferred gender identity
Email address*
example@example.com
Phone number*
Please enter a valid phone number.Format: +1 (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Caregiver/Guardian Information
What is your name?*

First NameLast Name
Pronouns
Please select "Other" to provide your preferred pronouns
Please enter your preferred pronouns
Date of birth*

MonthDayYear
Date
Email address*
example@example.com
Phone number*

Same phone number as my dependentEnter new phone number
Please enter your phone number*
Please enter a valid phone number.Format: +1 (000) 000-0000.
Address*

Same address as my dependentEnter new address
Please enter your address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Is this a new concern or a follow-up appointment?*

New concernFollow-up appointment
Would you like us to try and match you with the last Doctor who saw you if he/she is available?*

YesNo
Would you like us to try and match your dependent with the last Doctor who saw your dependent if he/she is available?*

YesNo

What is the main reason you want to see a doctor?*
" If you are experiencing severe chest pain or shortness of breath, please call 911 and/or go immediately to the nearest emergency department. "
What is the main reason your dependent want to see a doctor?*
Please select one of the following medications for a prescription refill.*
If you don't see your medication, please select "Other" to type out the name of your medication.
Please select one of the following:*
If you don't see your option, please select "Other" and describe in the tell us more section below.
Please type out the name of your medication(s).
Please type out the name of your dependent's medication(s).
If you have a preferred pharmacy, please enter the pharmacy name.
Please enter the fax number of your preferred pharmacy.
Please enter a valid phone number.Format: +1 (000) 000-0000.
Tell us more. Please describe the details for your visit.*
Tell us more. Please describe the details for your dependent's visit.*
Are you a Veteran?

YesNo
Please enter your Blue Cross ID*
Do you require a referral to a specialist?*

YesNoI'm not sure
If you know the details of the specialist type, clinic or physician, please provide them here ( optional ) :
*By requesting an appointment, you agree to Rocket Doctor’s Terms and Conditions, Email Communications Policy, Informed Consent, and Privacy Policy.
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Patient Information