CALL FOR AN APPOINTMENT TODAY.

419-334-3869

Appointment Request

Error sending appointment request

Please call the office to schedule an appointment.

Sending appointment request

Thank you

Your appointment request has been sent. Please note this is only a request. No appointment will be made for you until a CHS receptionist contacts you to schedule the appointment.

If this is an emergency, do not use this form. Please go to the nearest emergency room or call 911.

Please complete the form below to request an appointment. Please note this is only a request. No appointment will be made for you until a CHS receptionist contacts you to schedule the appointment. 

This online appointment request may be used by established medical patients only.

THIS FORM MAY NOT BE USED FOR DENTAL AND NEW PATIENTS. PLEASE CALL THE OFFICE FOR INFORMATION. 

Appointment Request Form

All fields are required to be completed.

Person Requesting Appointment:
Patient First Name:
Patient Last Name:
Patient Date of Birth:
Patient Address:
Patient City:
Patient State:     Zip:
Patient Primary Phone:
Reason for Request:
Office Location:
Scheduling Preferences: Please select the appointment day and time that is best for you.
Day Time

All calls will be returned the next business day. We will make two attempts within the next business day to reach you at the phone number provided. If your appointment has not been confirmed, please contact our office during business hours at 419-334-3869.

 

Stay Connected