Request an Appointment
Office Email
example@example.com
Doctor Name
Thank you for choosing Good Samaritan for your health care needs.
Complete the form below to request an appointment. A Good Samaritan team member will contact you within three business days (not including weekends or holidays) to find an appointment that best meets your needs. The team member will review your medical and financial information, including insurance coverage, before an appointment may be offered. If you’d like to schedule an appointment by phone, call your physician’s office directly or dial 812-882-5220 8 am – 4:30 pm, Monday – Friday to speak with the main switchboard and be routed to your physician’s office. Thank you for choosing Good Samaritan as your healthcare provider. If you are having a medical emergency, call 911 or emergency medical help.
PATIENT INFORMATION
Name
*
First Name
Middle Name
Last Name
Former Name
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Patient Gender
*
Male
Female
Have you previously received care at Good Samaritan?
*
Yes
No
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
*
Please enter a valid phone number.
*
Home
Cell
Work
Secondary Phone
*
Please enter a valid phone number.
*
Home
Cell
Work
Email
*
example@example.com
REQUESTER INFORMATION
Who are you requesting this appointment for?
*
Self
Other
PATIENT INSURANCE INFORMATION
Does the patient have health insurance?
*
Yes
No
I Don't Know
What is the name of your insurance?
MEDICAL CONCERN
What is the primary medical problem or diagnosis for your appointment request?
*
How long have you had this problem?
Days
Weeks
Months
Years
Are there additional medical problems you need assessed during this visit?
*
What medications are you currently taking?
*
If you would like to provide additional information to the appointment staff, please add it here:
*
Is your request due to a:
*
Work Related Injury/Illness
Motor Vehicle Accident
Other Liability Claim
None of the Above
Send Request
Should be Empty: