Demographic Form
If this is an emergency or if you are experiencing any of the following symptoms:
- Suicidal thoughts
- Chest or upper abdominal pain or pressure
- Shortness of breath-unable to walk across the room
- Sudden dizziness, weakness, numbness, or tingling (face, arm, leg)
- Sudden inability to speak
- Sudden confusion, changes in mental status, or loss of consciousness
- Sudden trouble seeing in one or both eyes
- Seizures
- Uncontrolled bleeding
- Severe or persistent vomiting or diarrhea
- Coughing blood, vomiting blood, or large blood in the stool
Call 911 immediately and DO NOT use Appointment Request.
