Request an Appointment

Complete the form below to start the process of scheduling an appointment at East Alabama Health.

First Name *

Last Name *

Address 1

Address 2

City

State or Province

Zip or Postal Code

Phone Number *

Social Security Number (Last 4 Digits)

Please only provide the last four digits.

Email Address *

Birth Date *

Comments *

Preferred Day of Week

Preferred Time of Day

Preferred Physician