Amity Medical Patient Support Form
We’re here to help. Please complete the form below and a member of our team will follow up with you as soon as possible.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Contact Method
*
Phone
Email
Either
Clinic Loaction
*
Harris
Monroe
Dallas
Randolph
Tyron
Type of Support Needed
*
Appointment Question
Billing or Insurance
Prescription/Medication Issue
Medical Records Request
Referral Question
Patient Portal Assistance
Staff Feedback
Complaint or Concern
Compliment or Recognition
Other
If Other, Please Describe
Details Of Your Request
*
I understand this form is not intended for medical emergencies. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room.
*
I acknowledge and understand.
I consent to being contacted by Amity Medical Group regarding this request.
*
I consent.
Submit
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