HomeContact Us Schedule an Appointment? Have a Question? Quick question, need to make an appointment? Get started below.You also can call us at (740) 383-2776 to schedule an appointmentIf this is an EMERGENCY, please dial 911 first! 1 Quest & Appt Form – LIVE New 8-03-2019 Have a quick question OR need to make an appointment? Start here.* indicates a required question to proceed. * indicates a required question to proceed. Contact Type?* I would like to schedule an Appointment I have a Question Question. We respond within 1 business day. If your need is more urgent, it is best to call the office at (740) 383-2776. Appointment. After you submit this form, we will get back with you within 1 business day. If your need is more urgent, it is best to call the office at (740) 383-2776.Patient StatusPatient Status*So that we can provide the fastest response. New Patient Current Patient – Over 1 year Current Patient – Seen in the last year (No Changes) Current Patient – Seen in the last year (Changes) You have NEVER been a patient.You ARE a patient here but have NOT been seen in OVER a year.You ARE a patient and have been seen in the past year AND have no change to your insurance OR your address.You ARE a patient and have been seen in the past year AND have CHANGES to your insurance OR your address.Patient InformationPatient Name* First Last DOB*Patient’s date of birth MM slash DD slash YYYY Patient Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient Phone*Patient Email* Enter Email Confirm Email Your InformationPlease submit your information IF different than the patient.* Same as the Patient / I am the patient I am not the patient Your Name* First Last Phone*Email* Enter Email Confirm Email Question or InquiryWhat can we help you with?*Insurance CarrierInsurance*Who is the patients Primary insurance Carrier? I do NOT have insurance Medical Mutual United Health Care Anthem Aetna Cigna/Greatwest Care Source Molina United Healthcare Community Plan Buckeye Parmount Insurance InformationPolicy ID#* Group Number#* Effective Date* MM slash DD slash YYYY Secondary Insurance Coverage* Yes No Secondary Insurance InformationIf applicableSecondary Insurance Coverage*Who is the patients Secondary insurance Carrier? Medical Mutual United Health Care Anthem Aetna Cigna/Greatwest Care Source Molina United Healthcare Community Plan Buckeye Parmount Appointment DetailsReason for visit*When we contact you to schedule your appointment we will discuss in more detail. If your need is urgent, please call us (740) 383-2776 Annual Exam I have a Problem Provider ChoiceWould you like to see a specific provider? Dr. Moodley Brandi Fields Qin Huang Allie Branham Any Provider Appointment Preference*Day and time preference you would like an appointment? Monday Morning Monday Afternoon Monday Early Evening Tuesday Morning Tuesday Afternoon Wednesday Morning Thursday Morning Thursday Afternoon Thursday Early Evening Friday Morning SubmitWhat is 14 minus 5?*Due to form abuse, we must ask this question. EmailThis field is for validation purposes and should be left unchanged.
