New Patient Form - The Community Health Center Of Lubbock

Name *

First

Last

Phone *

Email *

Email

Confirm Email

What additional information or request do you have? *

Additional Request Information (Sliding Fee Scale, Appointment, etc)

Please do not include any protected health information, such as, Social Security Numbers (SSN), Medical Record Numbers (MRN), etc. Do not include any payment information.

When is a good call back time? (Choose a future date) *

Date

Time

If you are a new patient seeking an appointment, provide some available dates. (Optional, our staff members will contact you)

Date

Time

Date / Time

Date

Time

Date / Time

Date

Time

How did you hear about us? (optional)

We appreciate you taking the time to answer this optional question.