New Patient Intake Form
Interested in becoming a patient at ASIA's International Community Health Center? Submit an intake form and our patient service representatives will reach out to you to schedule an appointment.
Patient Name:
*
First Name
Last Name
Email Address:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method:
*
Phone Call
Email Address
Both methods are acceptable
I am seeking:
*
Medical healthcare
Behavioral healthcare
Acupuncture services (Cleveland only)
Please note that if you are seeking acupuncture services, insurance will only cover these services if you have a referral from your primary care provider. Please contact your insurance company for specific details about coverage. Referrals should be faxed to (216) 361-1568.
*
I am seeking acupuncture services and understand the statement.
I am not seeking acupuncture services.
Preferred clinic location:
Akron
Cleveland
Either are acceptable
Language Preferences:
English
Nepali
Mandarin
Cantonese
Spanish
Swahili
Other
If you selected "Other," please write the preferred language below:
Submit
Should be Empty: