Request an Appointment Form

Request An Appointment
COVID-19 Testing, Telehealth Services, & More!

The online check helps speed up the process during your visit. We are also now taking walk-ins.

After your form is received, you will be contacted by the Clovis Urgent Care staff via email or phone call to confirm appointment date and time.

Reminder: If you enter our clinic, please wear a mask on for the safety of our staff and yours. Thank you.
Select a Reason *
Reason For The COVID-19 Test
Are you a new patient? *

Yes No Not sure
Name *

First Name Last Name
Date of Birth *
Format: (MM/DD/YYYY)
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number: *
Format: XXX-XXX-XXXX
E-mail *
Format: myname@example.com
How would you like to pay? *
Insurance Card: Front Side *

Cancel of
Insurance Card: Back Side *

Cancel of
Photo ID: *

Front Side ONLY
Cancel of
Health Concerns: *
Preferred Pharmacy (If medication is prescribed) *
Name and Address of Pharmacy
Select an Appointment Date & Time:
Terms & Conditions *

I understand that my time spot could be delayed due to unforeseen circumstances, but that Clovis Urgent Care does everything possible to accommodate my requested time spot. There may be a short wait when you arrive.
Should be Empty:

Request An Appointment