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860-437-4550
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CFA Medical Clinic-Request an Appointment Form
Client Name:
(Required)
First
Last
Client DOB:
(Required)
MM slash DD slash YYYY
Client Assigned Sex
Male
Female
Other
Language Spoken at Home:
Is the client under the age of 18?
(Required)
Yes
No
Parent/Guardian Name:
(Required)
First
Last
Parent/Guardian Cell Phone Number:
(Required)
Parent/Guardian Email:
(Required)
Cell Phone Number:
(Required)
Email:
(Required)
Would you like to request a medical appointment?
(Required)
Yes
No
Services requested
(Required)
(check all applicable)
Physical Exam (Annual, School Entry, Sports, Employment)
Flu Vaccine
Other vaccination
Other service
Disclaimer:
We are currently receiving a high volume of requests for services. Please expect return contact for scheduling in
5 business days
. Appointments can be scheduled by calling (860) 437-4550, option 3 to speak with a medical services representative. For urgent or emergent requests please call 911, or go to the nearest emergency department for assistance.
