Appointment request for (City)  
  
Health Clinic  
  
Contact Information
  
Name:
  
Zip Code:
  
Phone Number:
  
Email:
  
Preferred Language (Select one):


     
  
I prefer to be reached by (Select one):

  
  
If you give us a few more details, we can tell you whether you may qualify for Medicaid, CHIP or reduced health care premiums using a subsidy. Would you like the assister to look up whether you eligible and shorten your appointment time?
  
  
  
To save time at your appointment for Marketplace Health Coverage, you can tell your assister what parts of a health plan are most important to you. Would you like to share that information now?
  
  
Best days of the week for an appointment (Select three)






  
Best time of day for an appointment (Select two)