Request An Appointment

After submitting this form, a scheduler will contact you within 24 hours, Monday through Friday. For assistance, please call 606.780.5500. If you are experiencing a medical emergency, call 911 or go to the nearest hospital. St. Claire Regional Medical Center's Emergency Department is open 24 hours a day, 7 days a week.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email*
example@example.com
May we contact you about your appointment by email?*

YESNO
Patient Gender*
Date of Birth*

MonthDayYear
Date
Your privacy is important to us, so we will never share your personal information with others.

Your privacy is important to us, so we will never share your personal information with others.