Patient Suggestion Box
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info@chcl.tachc.org
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Please select from the forms below based on your request or suggestion.
Contact Simple
Complaint Form
Vendor Form
Patient Suggestion Box
Request Appointment
Fitness Sign Up
Contact Simple
Contact Us
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Name
*
First
Last
Email
*
Phone
*
Comment or Message
*
Please do not include any personal information such as SSN, MRN, Credit Card Numbers on any of our forms.
How did you hear about us? (optional)
Facebook
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Other
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Email
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Complaint Form
Complaint Form
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Name
*
First
Last
Phone
Email
*
Email
Confirm Email
When did the incident happen?
*
Date
Time
Where did the incident happen?
*
96 West
Arnett Benson Clinic
Chatman Clinic
CHCL Main Clinic
Community Dental Clinic
Medical Office Plaza
Parkway Clinic
West Medical
West Dental
Over the phone
Other
Provide a detailed description of the events that occurred during the incident.
Please do not include any personal information such as SSN, MRN, Credit Card Numbers on any of our forms.
Email
Submit
Vendor Form
Vendor Form
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Name
*
First
Last
Email
*
Phone
*
Vendor Name:
*
Vendor Website:
*
Service Description or Sales Pitch.
*
Message
Submit
Patient Suggestion Box
Patient Suggestion Form
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Which department do you have a suggestion for?
*
Adult Medical and Dental
Children's Medical and Dental
Women's Health
Behavioral Health
Fitness Classes
Outreach
Other
Subject
*
Message
*
Please do not include any personal information such as SSN, MRN, Credit Card Numbers on any of our forms.
Email
Submit
Request Appointment
Request Appointment Form
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Name
*
First
Last
Email
*
Phone Number
*
Have you been seen at CHCL before?
*
Yes
No
Reason for Appointment
*
Allergies
Cold
Diarrhea
Adult or Children's Dental
Ear Ache
Eye Infections or Redness
Fever / Headaches
Flu Shot
Indigestion
Pregnancy Testing
Sinus
Sore Throat
Sports Physical
Vomiting
Other
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?
*
Date
Time
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)
Other
Current Patient
Family/Friend
Facebook
Search Engine (Google, Bing, Yahoo)
TV
Radio
Billboard
We appreciate you taking the time to answer this optional question.
Comment
Submit
Fitness Sign Up
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Name
*
First
Last
Phone
*
Email
*
Which class are you interested in?
*
Walking Away The Pounds!
Zumba!
Step UP!
Prenatal Classes
Preferred Class Date
*
Are you a CHCL patient?
Yes
No
How did you hear about us? (optional)
Other
Current Patient
Family/Friend
Facebook
Search Engine (Google, Bing, Yahoo)
TV
Radio
Billboard
We appreciate you taking the time to answer this optional question.
Phone
Submit
Location
CHCL Main Business Center and Clinic
Direct Contact Information
1610 5th Street, Lubbock Texas, 79401
806-765-2611
info@chcl.tachc.org
