Request Appointment

We are here to help you make an appointment. To begin your request fill out the form below. We will contact you within 24 hours with information. If you submit your request on a holiday or Friday afternoon through Sunday, we will respond by the end of the next business day. If you do not hear from us within this timeframe, have questions, or perfer to make an appointment by phone, please call (405) 273-5801 or toll free 1- (800)-479-1993

Name *:

Address:

City:

State:

Zip:

Phone *:

Fax:

E-mail Address:

Date:

Patient's Name *:

Date of Birth *:
/ /

Contact Phone:

Physician *:

Preferred Day of the Week:

Morning or Afternoon: Morning Afternoon

By submitting this form you acknowledge the risk of sending this information by e-mail and agree not to hold the Shawnee Medical Center Clinic liable for any damages you may incur as a result of the transfer or use of this information. The use or transmittal of this form does not create a physician-patient relationship. More information regarding the confidentiality of this request can be found in our Privacy Policy.

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