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Kimball Health Services

Request an Appointment at the Kimball Health Services Clinic

Please select an answer for each question below, then click the submit button at the bottom.
When you submit this form, an admissions specialist will contact you to confirm your appointment date and time.

This form is used for requesting an appointment only. If you have an emergency please call 911.
* Please give a brief description of your health issue
* Are You A Current Patient? Yes     No    
* Do You Have Health Insurance? Yes     No    
  Name of Insurance Company
* Is Your Problem The Result of An Automobile Injury? Yes     No    
* Is Your Injury Part of A Workers’ Compensation Case? Yes     No    
* If This Is A Workers’ Compensation Case, Is This A New Injury? Yes     No    
* Have you had x-rays or MRIs taken elsewhere related to your current problem? Yes     No    
  If yes, where and when performed?
* Describe your current problem:
* Have You or Are You Being Referred To Us? Yes     No    
  If so by whom:
PATIENT INFORMATION
* First Name
* Last Name
  Middle Initial
* Date of Birth
  Home Phone
  Work Phone
  Cell Phone
* Address
Please provide full mailing address
* Email Address
* Appointment Request Date