Appointment Request

For your convenience, you may now schedule a non-emergent yearly exam or problem visit online. IF THIS IS AN EMERGENCY PLEASE CALL 911! Please note: we will do our best to get you in on the date/time that you’ve requested, however, in some instances this may not be possible. Your Yearly Exam should be scheduled one calendar year from your last Yearly. Thank you.

Patient Name

DAYTIME CONTACT PHONE NUMBER

DATE OF BIRTH

doctor

Office Location

REASON FOR VISIT

REQUESTED APPOINTMENT DAY 1 OF 3

REQUESTED APPOINTMENT DAY 2 OF 3

REQUESTED APPOINTMENT DAY 3 OF 3

DESIRED APPOINTMENT TIME

ADDITIONAL COMMENTS

ARE YOU A NEW PATIENT
yesno

INSURANCE PROVIDER

NAME OF POLICY HOLDER

POLICY HOLDER DOB

POLICY NUMBER

GROUP NUMBER

EFFECTIVE DATE

REQUESTS

Pay on Your Account

INFORMATION

Cancellation Policy

Careers

Forms

Insurance

HWWC Staff Only

LOCATIONS

Birmingham

Chelsea

Cullman

Gardendale

Rainbow City

Jasper

Tuscaloosa

IMPORTANT NUMBERS

Main Line
(205) 930-1800

Toll Free
(800) 264-1075

Business Office
(205) 930-1817

Surgery Scheduling
(205) 930-1828 Ext 1134
(256) 739-2626 Ext 102

After Hours Contact
(205) 930-1800

We will be closed Friday, Jan. 10 and Saturday, Jan. 11 due to inclement weather. Please call (205) 930-1800 to reschedule appointments. In an emergency, call 911 or go to nearest ER.