To request an appointment, please enter the information
and press the 'Send Appointment Request' button when you
are through. A representative from our Central Appointment
Desk will contact you to confirm your appointment. You
must be an adult (18 years old or older) to request an
appointment by E-mail over the Internet. If you are a
minor (17 years old or younger), please call 304-528-4600,
Extension 4548 to make an appointment.
Due to the nature of electronic mail, please do not use
this method of communication in an emergency situation.
Should you believe that you have an emergency, please
proceed to your nearest emergency facility.
If your need is not an emergency, please proceed.
When you press the "Send Appointment Request"
button, you consent to correspond with HIMG
staff by E-mail over the Internet.
You should use the Appointment Request Form below for
non-urgent appointments only.
PLEASE NOTE THAT HIMG CANNOT GUARANTEE THAT THE INFORMATION
YOU PROVIDE WILL BE CONFIDENTIAL WHEN SUBMITTED VIA E-MAIL
OVER THE INTERNET. BY PRESSING THE 'SEND APPOINTMENT REQUEST'
BUTTON, YOU AGREE TO RELEASE HIMG
FROM ANY AND ALL LIABILITY ARISING OUT OF OR RELATED TO
DISCLOSURES OF THE INFORMATION YOU PROVIDE VIA E-MAIL
OVER THE INTERNET.
If you prefer to make an appointment by phone, or if you
aren't sure of the appropriate department to make an appointment
with, please call 1-304-528-4600, Extension 4548 and ask
for the Central Appointment Desk.
Your name and phone number are required so we can contact
you to confirm your appointment. |
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name: |
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Reason for Appointment and/or Primary Complaint:
Do not enter confidential information or comments in the
space provided below. The information or comments you
enter below will be shared with HIMG
Clinic staff and/or placed in your medical record at your
health care provider's discretion.
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For
new patients only - Primary Care Clinic (Family Practice
or Internal Medicine) location where you would prefer
your appointment:
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Department you would like to be seen in:
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Please include your e-mail address so that you will receive
an automated response to notify you that your query was
received. You will receive a personal response to your
query from a member of the HIMG
staff between the hours of 8:00 am and 5:00 pm.
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| Email
Address: |
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Are
you certain you wish to send this over E-mail?
Yes
No |
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