Help for Finding a Doctor

*For medical emergencies, call 911 immediately

Please provide the name of the Health Center
Please tell us the following:

(Do not include any personal health information you would like to keep private.)

  • Why you need help finding a doctor
  • Where you would like to see a doctor
  • Other details about your request (optional)
Please provide the following information.

All fields are required.

How should we contact you if necessary?
If phone, when should we contact you?