Avicenna Appointment Request Form
Para español: Haga clic aquí

Please fill out the form below and select your appointment preferences. Please note that this form does NOT confirm your appointment. We will contact you via phone call, email, or text to help you schedule an appointment, typically within 3-5 days. Thank you! *Please note that the contact information you provide is private, secure, and will not be shared with any individual, organization, or government agency outside of Avicenna Community Health Center.* 
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Full Name *
Phone Number *
E-mail
How would you prefer to be contacted? *
Which language are you most comfortable speaking and understanding? *
Avicenna currently offers the following services for patients age 18 and older.

Primary Care (1 hour + 30 min Case Management appointment for new patients) : See a medical provider for new medical concerns, chronic disease management, annual and work physicals, and more

Lifestyle Medicine (30 mins): Get help with building exercise plans, nutrition goals, mental wellness, and sleep hygiene

Case Management (30 mins): Find resources to support housing, food, insurance, and other important needs (can be over Zoom)

Eye Clinic (30-75 mins): See an eye doctor for comprehensive vision screening, evaluation of eye symptoms, and management of common conditions. Note that appointments may include a dilated exam, which temporarily blurs vision and affects your ability to drive. Unfortunately, we no longer offer glasses prescriptions.

Women's Health (30 mins): See a gynecologist for well woman check-ups, cervical cancer screening, UTI care, contraception, irregular periods, and more. Unfortunately, we cannot provide pregnancy care.

Dermatology (30 mins): See a skin doctor for comprehensive services including full skin examinations, diagnosis and treatment of skin diseases, screening for skin cancer, diabetic foot examinations, wound debridement, drainage of abscesses/cysts, wart treatments, skin biopsies, and education on skin health. NOTE: We currently do not have any available appointment slots for our dermatology clinic. if you request this service you will be added to the waitlist and contacted when appointments become available.

ENT (30 mins): See an ear, nose, and throat doctor for a full range of services, including a comprehensive head and neck exam, diagnosis and treatment of ear infections, hearing issues, earwax removal, voice and throat disorders, sinus issues, and education on maintaining ear, nose, and throat health.
Which services would you like to come in for? (select as many as you would like) *
Required
If you are interested in the Eye Clinic, please check Yes to answer a few more questions. *
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