Appointment Request

Important Notice:

If you think that you may have a life threatening emergency, call 911 for transport to the closest Emergency Room. If you have a medical concern that you feel needs urgent attention, please call one of our clinics directly.
E-mail appointment requests are promptly responded to on the same business day. Requests received when the clinic is closed are responded to on the next business day.
The email requests below are not confidential or secure. If you are concerned about the privacy of your information, please contact the clinic directly to request an appointment.

Appointment Request Form
* First Name:
* Last Name:
Middle Initial:
* Date of Birth:	format: 5/10/2009
* Primary Phone:
Alternate Phone:
* Email:
* Confirm Email:
Preferred contact method: Phone Email
Are you a new patient at Highline Medical Group? Yes No
Who is the appointment for? Me Someone Else
Your Insurance:	** insurance is only accepted by designated clinic
* Clinic Location:
Specialty:
Preferred Gender of Provider: OR
* Please state your reason for visiting:
* Options For Scheduling Appointment: First Available Appointment Schedule an appointment for a specific day of the week
* Desired Appointment Time: