Appointment Request Form

“To Provide Quality Healthcare for Everyone”

"*" indicates required fields

Please fill out the details in the form below to submit a new appointment request for Gateway Community Health Center. DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment request only.

Patient Contact Information

Name*

First Middle Last Suffix

Date of Birth*

Gender*

Male

Female

Address*

Street Address City State ZIP Code

Email*

No Email

Phone Number*

Phone Type*

Patient Insurance

Is the patient an insurance holder?

Yes

Insurance company*

Policy ID Number

Appointment Details

How did you hear about us?

Referring provider name (if applicable)

Select reason for appointment*

Appointment Preferences

Preferred locations*

Preferred day of week

Preferred time of day

Additional Information

Please specify your exact reason for visit

Comments

This field is for validation purposes and should be left unchanged.

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Patient Information

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Sliding Fee Discount

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Patient Rights & Responsibilities