Appointment Request Form

Please fill out the following form to request an appointment with Family Health Center, Inc.

Personal Contact Information

First name*

Last name*

Date of birth*

Month

Day

Year

Zip Code

Email*

Phone*

Appointment Information

Provider Type

Location*

Best Date and time*

Month

Day

Year

Time

:HoursMinutes

Please select the best date and time and someone will be in touch with you.

Please provide any additional details about this appointment.

I declare that the info I’ve provided is accurate and complete.

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Family Health Center is a private, non-profit corporation 501(c)(3) which is governed by a community-based Board of Directors. The Board of Directors consists of members who use Family Health Center as their center for primary healthcare and who are community representatives.

This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).