Request Appointment | Cornerstone RHC

Name*

First Last

Email*

Phone*

Are you a new or existing patient?*

New
Existing

Are you requesting a COVID-19 antibody test?*

Yes
No

Please complete and upload the COVID-19 test new patient paperwork to request an antibody test. This paperwork must be completed prior to appointment scheduling for any new patient.

Date Preference*

Appointment requests must be confirmed by staff before they are finalized. Please call the office for urgent requests.

Preferred Times

Early morning
Late morning
Around noon
Early afternoon
Late afternoon
Other

Other Preferred Times

Select your insurance plan(s).*

Enter your insurance company's name.

Waiver*

I acknowledge that I am not including any protected health information (PHI) in my inquiry. I understand that any such information should be presented in person or securely over the phone with my health care provider. PHI includes, but is not limited to, any information that relates to 1) the past, present, or future physical or mental health or condition of an individual, 2) the provision of health care to an individual or 3) the past, present, or future payment for the provision of health care to an individual that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

I accept

Comments

This field is for validation purposes and should be left unchanged.

Mon	8:30AM-4:30PM

Tues	8:30AM-4:30PM

Wed	8:30AM-4:30PM

Thurs	8:30AM-4:30PM

Fri	8:30AM-4:30PM

Sat	CLOSED

Sun	CLOSED