Patient Medical Request

If you need immediate medical attention please dial 911 or go to your nearest emergency room. Please fill out the details and you will be contacted within 3 hours for non-emergencies and 60 minutes for a medical emergency.

UPDATE YOUR PHONE TO ACCEPT CALLS FROM CALLER-ID BLOCKED NUMBERS.

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I acknowledge that this request may be subject to $50 After-Hours consultative fee for non-pregnant patients and is not a covered benefit of my insurance. *

I Agree

What is your first and last name? *

Please select your Provider: *

Enter Your Date Of Birth

For the fastest response you agree to receive a message from the on call Provider to this number. Number forwarding and Google voice are not secure and will not work.

Enter Your Mobile Phone Number * If you need a call back from the on-call physician within 60 minutes select Yes. By selecting No, please allow up to 3 hours for a response between the hours of 9 AM and 9 PM. Non-urgent messages received after 9 PM will be returned the next day.

Is this a true medical emergency? *

Yes

Are you pregnant or currently trying? *

Yes

Please Enter Your Message for the Provider On Call *

Pharmacy Phone Number If you will be needing a prescription or requesting a refill please enter your pharmacy phone number, closing time and allergies before submitting this request.

I Confirm the Pharmacy is Open

Yes

Please Report Any Medicine Allergies:

No Medicine Allergies

Penicillin

Aspirin

Sulfa

Non-Steroidal Anti-Inflammatory Medications (Ibuprofen, Advil, Motrin, Aleve)

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