NEOMED Health Care - Online Appointment Request Form

NEOMED Online Appointment Request Form

NEOMED Health Care | 4211 St Rt 44, Ste 203 (2nd floor), Rootstown, OH 44272 | 330-325-3202
Name*

First NameLast Name
Are you a student currently enrolled at NEOMED Health Care?*
Patient Birth Date*

MonthDayYear
Patient Gender assigned at Birth*
Patient E-Mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the reason for your requested appointment?*

New Patient Visit (Establish Care)Return Patient Visit (Follow-Up)Acute Visit (ex: cold/cough; infection; pain)Annual Medicare Visit (for Medicare enrollees only)Annual Wellness VisitCounseling Services (New or Return) - by CounselorPsychiatry/ Mental Health Visit (New or Return) -by Provider (MD/APP)Medication Assisted Treatment/ Addiction Services (New or Return)
You may select your preferred provider, however, for acute visits the earliest available appointment will be scheduled***

No PreferenceAshley Miller (APRN, FNP-C) - Family MedicineBehavioral Health Counselors - Mental Health ServicesDr. Tiffany Thomas-Lakia (MD) - Psychiatry/Mental Health (for Students Only)Kelly Marsh (PMH-APRN) - Psychiatry/Mental HealthDr. Jason Kolb (MD) - Addiction Medicine
Please select your PREFERRED appointment date and time. *
This request DOES NOT guarantee an appointment at the requested date/time. A representative from NEOMED Health Care will call you to schedule your visit.

By submitting this form you are consenting NEOMED Health Care to create your patient profile. Please monitor your e-mail for a message with a link to create a MyChart for our center. Once you've established a MyChart, you can update further demographics, upload insurance information and request appointments.

Please call 330-325-3202 to contact us if you have any questions.

We look forward to seeing you!
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NEOMED Online Appointment Request Form