Online Appointment Request – Urogynecology

YOUR INFORMATION

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Email *

Preferred Contact Method *

Date of Birth *

MM/DD/YYYY

Insurance *

Who is your primary care physician?

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

YOUR APPOINTMENT PREFERENCES

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

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

Early Afternoon (12:00 to 2:00 p.m.)

Late Afternoon (2:00 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 – Urogynecology

Online Appointment Request – Urogynecology