Appointment Request
Full Name
*
First Name
Last Name
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
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
Back
Next
Please type the names of the medications you are currently taking.
Back
Next
Past Medical History
Scarlet Fever
Diphtheria
Measles
German Measles
Mumps
Whooping Cough
Chicken Pox
Tuberculosis
Rheumatic Fever
Frequent or Severe Headaches
Ear, Nose or Throat Problems
Urinary Tract Infections
Paralysis
Trouble Sleeping
Loss of Memory, Amnesia
Indigestion or other Stomach Problems
Hemophilia (Bleeding Disorder
Depression, Suicidal Thoughts
Arthritis or Rheumatism
Diabetes
Asthma/Hay Fever/Shortness of Breath
Hernia
Appendicitis
Tumor or Cancer
Polio
Pneumonia
Eye Trouble/Glaucoma
Thyroid Trouble or Goiter
Sinus Problem
High Blood Pressure
Heart Problems
Back Problems
Broken Bones
Fainting Spells or Dizziness
Nervousness, Anxiety or Panic Disorder
Other
If you selected "other" on the previous question please fill in the box with the specific illness/injury
Submit
Should be Empty: