WJMC - Physician Office Scheduling

The Family Doctors
Physician Office Scheduling

If you have an emergency call 911 immediately or go to the nearest Emergency Room.
WE DO NOT RESPOND TO EMERGENCIES THROUGH THIS WEBSITE.

Identification
First Name:	Middle Init:
Last Name:
Address:
City:	State:
Zip:
Returning Patient?:
Gender:
Marital Status:
Employment Status:
Employer:
Date of Birth:
Last Four Digits of SSN:	Enter 0000 if not applicable.
Primary Phone:
Secondary Phone:
Email Address:
How do you want us to contact you?:	EmailPhone
Insurance Type/Name:
Reason for Visit:

Preferred Date/Time
Date:

Time:
	Please check box to request the next available appointment.

Preferred Provider
Location:
	Please check box to request any location if preferred location is not available.

Provider:
	Please check box to request any provider at this location if preferred provider is not available.

REMINDER
Please contact us if you are unable to make it to this appointment. Please bring your insurance card, picture ID and arrive 15 minutes early.

Thank you for choosing West Jefferson Medical Center and The Family Doctors for your healthcare needs.