Bureau County
Health & Wellness Clinic

SCHEDULE AN APPOINTMENT:

Name:    Phone:

Reason for Calling: Please describe symptoms, what happened, etc:
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Are you calling to schedule a lab? Yes: No: Don't Know:
Name labs:

Are you calling with a question about your medications or PAP
(Patient Assistance Program)? Yes: No: Don't Know:
Questions/Comments:

We are normally open Tuesdays, Wednesdays, and Thursdays from 9am to 2pm, but schedule Doctor's Clinics when they are available.   Please tell us about your schedule below. Try to be as flexible as possible.

Do you have insurance? Yes: No: Don't Know:

Availability of services is based on yearly income and family size:
       What is your annual family income?
       How many people live in your household?

If you are a new patient, please provide:
       Address:

   Current Meds & Dosages:

   Allergies:

      Date of Birth:
      Email: