Request an Appointment

After completing and submitting the form below, a staff member will contact you to schedule your appointment.  For same-day appointments, please call Alleghany Family Medicine/Alleghany Health Services/Urgent Care at 336-372-5511.  If this is an emergency, call 911.

Appointment Details

For which practice would you like to schedule an appointment?Alleghany Family MedicineAlleghany Health ServicesUrgent CareAlleghany Health Specialty Clinic (includes Pulmonary, Cardiology, Orthopedics, Hematology/Oncology, Podiatry, ENT and Urology)

Reason for Appointment/Other Information *

Do you have a Primary Care Doctor? *YesNo

If yes, please provide name.

Personal Information

First Name *

Last Name *

Date of Birth *

Month *

Day *

Year *

Is the patient under the age of 18? *YesNo

Contact Information

Phone Number *

Email Address *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

I prefer to be contacted by *PhoneEmail

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