Schedule an Appointment with our Connected Care RN

Thank you for your interest. Please fill out the questions below to get started!
Are you a Lackey clinic patient?*

YesNo
In order to enroll you must become a Lackey Clinic patient. Please apply: https://lackeyclinic.org/apply/
Name*

First NameLast Name
DOB: MM/DD/YYYYPhone Number: (area code) ###-####
Email: Lackey Clinic ID
Consent for texting *

I agree to send and receive text messages from my health partner. Please remember that normal text messages are not encrypted and there is always a risk of exposure. Please do not share private information such as social security number via text message.
Electronic Signature*

I understand that by typing my name in the below textbox and clicking "Submit", I am electronically signing this document.
Date*

MonthDayYear
Date
Please type your first and last name into the textbox below as your electronic signature.*
Please let us know a good time from Monday to Thursday, between 9:30 AM and 3:30 PM to schedule your first IN Person appointment at Lacky Clinic. This appointment will not be considered official until you have received a text verification from the clinic confirming this date and time. *
Example: February 14, 2024, at 2:00 PM
Should be Empty:

Thank you for your interest. Please fill out the questions below to get started!