• Non Emergency Contact Form

    If you are having a medical emergency, please call 911 or go to the nearest emergency room. If you are interested in becoming a patient at CVIM, please call us at 814-231-4043 or submit your information below. After completing this form, someone from CVIM will call you, review your answers, and schedule you for an eligibility meeting, if appropriate. After you complete your eligibility meeting and are established as a patient, you will be scheduled with a medical or dental provider. Thank you!
  • May we contact you at the phone number provided?*
  • May we leave a message?*
  • Do you live or work in Centre County?*
  • Are you currently enrolled as a Penn State or Lock Haven student?*
  • If yes, have you been denied treatment from University Health Services?
  • Have you been serviced by this clinic before?*
  • Are you in the US on a temporary visitor visa?*
  • Do you have any health insurance?*
  • Do you have any of the following insurance/benefits? *Check all that apply**
  • Have you been disenrolled from Medical Assistance or MAWD in the last year?*
  • Are there any veterans in the household?*
  • If yes, has the veteran been denied benefits at the VA Clinic?
  • Please specify if the amount above is:*
  • What services are you in need of at this time?*
  • Do you need help filling out forms? *Due to illness, physical limitation, translation problems, reading or writing difficulty**
  • Should be Empty: