Form

Appointment Request
Full Name*
First Name Last Name
Birth Date*
Month Day Year
Primary Phone*
- Area Code Phone Number
Alternate Phone Number
- Area Code Phone Number
E-mail*
Do you take any medication?*

Yes No
Do you have any Past Medical History (Illness or Injury)*

Yes No
Please fill in the date and time of your desired appointment. *Make sure you check the available appointment times on the website**
/ Month / Day Year
at
: Hour Minutes
Please select the reason for your appointment.(may select more than 1)

Allergy symptoms Asthma Blood Pressure Check Blood Sugar Check Chest Pain Cold/Flu symptoms Vision/ Eye Problems Depo-Provera Injection Follow Up visit Stomach Problems Headache Infection Injury Men's Health Physical Pneumonia Pregnancy test Routine Lab STI testing TB test Upper Respiratory Infection/Coughing Urinary Tract Infection Women's Health/PAP smear Wound Other
Would you like an appointment reminder?*

Yes No
What is the best method to reach you for a reminder?

Primary Phone Number Alternate Number E-mail Text Message
If you would like a text message reminder please specify which phone number to use.

Primary Phone Number Alternate Number
Preferred Pharmacy*

K-Mart Schnucks Super D Target Wal-Mart (Stadium Blvd) Wal-Mart (Supercenter Dr) Walgreens (MO Blvd) Walgreens (Eastland Dr) Walgreens (Truman Blvd) Whaley's (East End) Whaley's (Southwest) Whaley's (Amazonas)
Do you have Student Health Insurance?*

Yes No

Appointment Request