Request an Appointment

Please fill out the form below and click on the submit button at the bottom of the page to send. A representative will then contact you with appointment options within two business days

Note: This form is NOT intended for urgent appointments, dental appointments or any appointments that you may need within three business days.

If this is a medical emergency, immediately call 911 or go to the nearest emergency room.

Additional Information

Urgent Appointments

If you wish to request an appointment within the next three days, call 706-721-CARE (2273) or 800-736-CARE (2273).

Dental Appointments:

To request an appointment for dentistry, please call 706-721-2371 between 8 a.m. - 5 p.m. EST, Monday-Friday.

Privacy and Security:

This online appointment request is secure (SSL technology) and information submitted will not be shared with persons outside the appointment making process.

Personal Information

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Last name

*  

First name

*  

Date of Birth (mm/dd/yyyy)

*  

SSN (Last four digits)

Sex

Address

Zip Code

Phone Number

*  

E-mail Address

*  

Additional Information

Insurance Company

Select the specialty of the appointment you are requesting

Reason for Appointment

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* Your information will take a moment to process.

To avoid duplicate submission, please do not click on the back button or hit submit more than once.