Request an Orthopedics Appointment Online

YOUR INFORMATION

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Email *

Preferred Contact Method *

Date of Birth *

MM/DD/YYYY

Insurance * Insurance

Will you need transportation assistance for this request? (AGH is able to provide transportation to and from your non emergency appointment for a low cost. Select yes to learn more)

Yes

No

Adjuster/Case Manager Name *

Adjuster/Case Manager Phone *

Which provider would you like to see? *

Are you a new or existing patient? *

New patient

Existing patient

Choose your preferred location (check all that apply). *

Artesia

Carlsbad

No preference

What is the reason for your visit? *

What is the reason for your visit?

YOUR APPOINTMENT PREFERENCES

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

Morning (8:00 to 11:00 a.m.)

Afternoon (1:00 to 4:00 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.