My Medical Care

MAKE AN APPOINTMENT, REFERRAL, OR RESULTS REQUEST

Please fill out the form below to make an appointment, referral, or results request. After your request is completed, a Medical Care employee will contact you to confirm your request.

Name*
Phone*
Alt Phone
Email
Account Number
DOB*
Month/Year
/
New Patient
No Yes

Type of Request*

Appointment Info

Preferred Time
8 AM - 10 AM 10 AM - 12 PM 12 PM - 2 PM
2 PM - 4 PM 4 PM - 6 PM Anytime

Date request
First Available 1 - 2 weeks 2 - 4 weeks
1 - 2 months 2 - 4 months 4+ months

Additional Information / Requests

*required