Patient Appointment Request Form

You can also schedule an appointment directly by calling us at:

Pahrump: 928-237-4418
Laughlin: 928-237-4418
Fort Mohave: 928-768-2558

Patient Information

First Name

Last Name

Date of Birth

Gender

Male

Female

Phone Number

Address

City

State

Zip

Insurance Name

Policy Number

Group Number

Medical Information

Symptoms/Complaint

Your information will be encrypted.

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