Request an Appointment

If this is an emergency, please call 911.   

*First name:

*Last name:

  

*Date of birth (mm/dd/yyyy):

*Phone number:

*E-mail address:

*Reason for appointment/Symptoms:

 
Are you an employee/family member of our medical center?
 
 

*indicates a required field  

Our staff will contact you by telephone to establish your appointment. A call will be made to you on the first business day following your submission of this form. Call Center hours are 8:30 am to 4:30 pm.  

 
   
 

If you prefer, you may reach us by phone at
336-716-WAKE or 888-716-WAKE (9253).