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Appointment Request Form
Please fill-in the form below and request an appointment
Have you been seen at CHCL before?
Reason for Appointment
Adult or Children's Dental
Eye Infections or Redness
Fever / Headaches
If you have an emergency, please contact 911 or go to an emergency center.
Give us a brief description of your symptoms.
Please do not include any information such as your SSN, MRN or any other personal number on this form.
Preferred Date and Time to be seen?
We do not guarantee that you will be seen on the day you choose, this is based on availability. A CHCL representative will call you back to confirm appointment dates.
How did you hear about us? (optional)
Search Engine (Google, Bing, Yahoo)
We appreciate you taking the time to answer this optional question.
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