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:

 
   
 

*indicates a required field  

Our staff will call you on the first business day after you submit this form. Call Center hours are 8:00 am to 5:00 pm, Monday - Friday. Thank you!  

 
   
 

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