Language
English (US)
Spanish (Latin America)
Request an Appointment at Circle Care Center - Glastonbury
Use the form below to request an appointment at Circle Care Center - Glastonbury. Please note that all appointment requests will be confirmed by our staff within 1-2 business days. If you need a same-day or next-day appointment, please give us a call at 860-657-0764. **If you are experiencing a medical emergency please call 911.**
Name
*
First Name
Middle Name
Last Name
Legal Name (If different from above)
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number (Cell)
*
Please enter a valid phone number.
Are you currently a patient at Circle Care Center?
*
Yes, I am a current patient.
No, I am a new patient.
No, I am a returning patient.
Which of our providers are you requesting an appointment with?
Dr. Kenneth Abriola, MD, MPH
Al Zucchetto, APRN
No Preference
What is the reason for your visit?
*
Primary Care/Annual Physical
Diagnostic Appointment (Are you feeling ill?)
Sexual Health/STI Testing and Treatment
HIV Treatment
HIV Prevention (PrEP & PEP)
Other
What days/times work best for you?
Please note that our clinical hours are Monday - Friday 8:30am - 4:30pm.
How did you hear about us? Please select the most accurate answer
*
Please Select
Another Patient/Word of Mouth
Triangle Community Center (TCC)
Mid Fairfield Aids Project (MFAP)
Doctor Referral
CCC Employee
Insurance Provider
Marketing Event/Pride Event
A friend/Colleague
TV Ad
Internet Search
Saw Flyer at local LGBTQ+ establishment
Submit
Should be Empty: