Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Kimball Health Services

See our Health Provider Calendar here

Request an Appointment at the Pine Bluffs Health 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.
* Do you need an appointment for? Family Medicine     Cardiac Specialty Clinic     Skin Care Specialty Clinic    
* Are you a current patient? Yes     No    
* Do you have health insurance? Yes     No    
  Name of insurance company?
* If this is a workers’ compensation case, is this a new injury? Yes     No    
* 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