Appointment Request Form

IF YOU NEED TO SEE THE DOCTOR TODAY, DO NOT USE THIS FORM.

Note: This form should be used ONLY FOR NON-URGENT appointments. If you are experiencing severe shortness of breath, chest pain, uncontrollable bleeding, or any other emergency situation, please seek treatment at Laurens County Hospital before attempting to call us. Laurens County EMS can be reached by calling 911.
Please select an option below * Fields in Red are required.
New Appointment  
Cancel Appointment    Original Appointment Date
Cancel Notes: 
PATIENT INFORMATION
First Name Last Name
Home Phone Work Phone
Cell Phone Email
Date of Birth Gender
PERSON COMPLETING THIS FORM
Name Relationship
INSURANCE INFORMATION
Insurance
Plan ID Insured
Other
APPOINTMENT INFORMATION
Provider
Type of Visit
Appointment Notes
SCHEDULE APPOINTMENT FOR
First Available OR Preferred Date
OR Other  
Preferred Week/Month
Preferred Day
Any Mon Tues Wed Thurs Fri
Preferred Time
Anytime Early AM Late AM Early PM Late PM
Check all information before submitting.
Phone: 833-5986

Address:
23013 Hwy. 76
Clinton, SC 29325

Summer Office hours:
May-July 2007
Mon. 7:30am-7pm
Tues.- Fri. 7:30am-5pm
Sat. - 9am - 11am

If you need assistance after normal office hours, call the Laurens County Hospital at 833-9100 and have our on-call physician paged.

IN AN EMERGENCY

If you are experiencing severe shortness of breath, chest pain, uncontrollable bleeding, or any other emergency situation, please seek treatment at Laurens County Hospital before attempting to call us.

Laurens County EMS can be reached by calling 911.