Online Appointment Request - Cardiology - Artesia General Hospital

YOUR INFORMATION

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Email *

Preferred Contact Method *

Date of Birth *

MM/DD/YYYY

Insurance *

What is the reason for your visit? *

What is the reason for your visit?

Are you a new or existing patient? *

New patient

Existing patient

NOTE: If you are a new patient, you must have a referral and your previous medical records before we can schedule you for an appointment.

YOUR APPOINTMENT PREFERENCES

Which time(s) of the day would you prefer your appointment? (Check all that apply.) *

Morning (8:00 to 12:00 p.m.)

Afternoon (1:00 to 5:00 p.m.)

Which day(s) of the week would you prefer your appointment? (Check all that apply.) *

Please provide any additional details about your request.

Consent Form *

I acknowledge that this appointment request form requires me to provide protected health information (PHI), which will be used to schedule an appointment at Artesia General Hospital. By submitting this form, I consent to this information being disclosed to the scheduling office, as well as receiving notifications via my requested communication method for scheduling purposes. If email is my preferred method, I understand I may receive unencrypted emails from a scheduler that may contain PHI, such as my name and the type of appointment I have requested.

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Online Appointment Request – Cardiology

Online Appointment Request – Cardiology