Patients

Becoming a Patient

To become a patient at our community health center, please contact us or fill out the online form below to make an appointment. Our new patient account representative will determine how quickly you need to be seen and advise you on what to bring to your first appointment.

If you have a recent HIV/AIDS diagnosis, please click here to learn how to become a patient.

Patient Information:

Who is making the appointment? *

If you are not the patient, please let us know what organization you are referring from

First name *

Middle initial

Last name *

Date of birth *

Address *

Apartment / Unit #

City *

State *

Zip code *

Email address *

Phone number (XXXXXXXXXX) *

Mobile phone number (XXXXXXXXXX)

Work phone number (XXXXXXXXXX)

* This is a printer friendly version of the original page, made to save you ink and paper.

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Becoming a Patient

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Becoming a Patient
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For Current Patients

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