Complete the form to request an appointment
Complete the form to request an appointment. Once the form has been submitted, our team will call or text you with next steps.
Name
*
First Name
Middle Name
Last Name
Cell Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
If you are getting referrals, labs, or other orders, our team will need your Social Security Number.
What is your race?
American Indian or Alaska Native
Black/African American
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Decline to asnwer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Our office offers office visits, telehealth (video) visit, house call visits. Telehealth visits often occur same-day. Which would you like to schedule?
*
Office visit
Telehealth
House Call
I'm not sure - I'd like to talk to someone
I'm pre-registering and don't need an appointment now.
When would you like your appointment to be scheduled?
I'd like to be seen/called quickly
I'd like to be seen/called today or tomorrow
I'd like to be seen/called within the next week
Let us know the reason for your appointment
Have you seen us before as a patient at Sharon City Health & Wellness?
*
No, I have seen you before
Yes, I am a new patient, or I need to complete a consent form
Welcome back! Has your insurance changed since your last visit? If so, we will ask you to upload your new insurance cards.
Yes, it has changed
No, it is the same
Submit
Should be Empty: