Request Appointment Form - The Community Health Center Of Lubbock

Name *

First

Last

Email *

Email

Confirm Email

Phone Number *

Have you been seen at CHCL before? *

Yes
No

Is the patient a child? *

Yes
No

Reason for Appointment *

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)

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