Requesting Appointment

Our office will contact all new patients on the phone number they provide to confirm a time for the selected date or discuss an alternative.

Once you fill and send your appointment request, please make sure you print and fill Patient Communication Consent Form and Policies of Continuum Health Care and bring them with you.

Demographic Information
Billing Information

Financial Guarantor (Party responsible for billing)

Medical Information

Medication List (Please list all Current Medications Including Vitamins/Supplements)

Allergies: (Please include allergies such as Medication, food and others)

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