Schedule 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

* Last Legal Name

* First Legal Name

Middel Initial

* Email Address

Gender : Male Female Other

* Full Address, Apt #

* City

* State

* Zip Code

* Primary Phone #

* Date Of Birth

Select Appointment Date

* Reason for visit

Billing Information

Financial Guarantor (Party responsible for billing)

Check if Self

Last Legal Name

First Legal Name

Middel Initial

Full Address, Apt #

Primary Phone #

Medical Information

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

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

Internet

Flyer

Insurance

Friend

Driving By

Other

In case of problems in filling out the form, please do let us know.

Call Us: 913-954-8500