**Requests are for non-urgent visits. If you have an urgent medical need, please call the office at 336-992-1234 to schedule an appointment.**

Who is the appointment for? *   

Date of birth of the patient?      

Have you ever been seen at
Laurel Creek Family Medicine?   Yes  No

If no, have you submitted an
online Initial Health Form?         Yes  No   N/A

Please select day preference       First Choice Monday Tuesday Wednesday Thursday Friday None       OR   Second Choice Monday Tuesday Wednesday Thursday Friday None

Time preference?                        First Choice Early Morning Mid-Morning Lunchtime Early Afternoon Late Afternoon   OR    Second Choice Early Morning Mid-Morning Lunchtime Early Afternoon Late Afternoon

Reason for visit?                        

Phone number to contact for
appointment confirmation?         OR   Alternate

E-Mail Address                         

Please choose provider               Please Select Provider Alison T. Snider, M.D. Karen M. Timbrook-Dillow, PA-C Sandra L. Einhellig, PA-C Daniel J. Bryan, PA-C