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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
Date of Birth
*
-
Month
-
Day
Year
Date
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
Corey Hudson, LMSW
No Preference
What is the reason for your visit?
*
Diagnostic Appointment (Are you feeling ill?)
Sexual Health/STI Testing and Treatment
HIV Treatment
HIV Prevention (PrEP & PEP)
Gender Affirming Care
Behavioral Health (Counseling)
Vaccine (Covid Booster and/or Flu Shot)
MPOX Vaccine
Primary Care/Annual Physical
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
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