1001 Noble Street
Fairbanks, Alaska 99701
Phone (907)459-3511
Toll Free (888)459-3500
Fax (907)459-3588

Family Practice Appointment Request

Fill out the following information (bold fields are mandatory) and click 'Submit'.


First Name:
Middle Initial:
Last Name:
Date of Birth:
Email Address:
Home Phone:
Business Phone:
Requested Doctor/PA:
Are you PA Clinic eligible?:
Reason for Appointment
Please be specific as we select an
appropriate amount of time for
your appointment according to your symptoms:
Best Days for the Appointment: Mon
Tue
Wed
Thu
Fri
Sat
Best Dates for the Appointment:
To:
Best Times for the Appointment:
To:
Other Comments:

Do you need any prescriptions refilled to hold you over until the appointment?
If so,which prescriptions?
Preferred Pharmacy:
Do you have enough left to give 48 hours notice for the refill?:
Drug / Dose


 



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The information provided through this web site is for general informational and educational purposes only. The information provided herein, is not intended as a substitute for consultation, diagnosis, or treatment from a licensed professional physician. If you are in need of medical attention or have questions of a medical nature you are urged to consult with a licensed physician immediately.

The user of this web site is also advised that this is not a secure web site. Although Tanana Valley Clinic strives to maintain the confidentiality of communications, the user is advised that confidentiality is not guaranteed. E-mail communications sent through this site, even those which might otherwise constitute confidential patient/physician communications, are not guaranteed to be confidential.

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Last accessed: Sat Jul 26 23:29:25 - 2008
Last changed: Wed Aug 17 12:34:24 - 2005

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