Disclaimer: This is not a substitute for medical advice. If you think you may have a medical emergency, call 911 or go to the nearest emergency room immediately.


Have you filled out a consent form? if not please go to acmhealthline.com/consent-form and fill it out before proceeding with the intake form here.

If you're here, it is for one of two reasons, you have a health concern, or you're preparing against the possibility that you may need some medical advice in the future. Either way, we invite you to use the contact form below to reach us initially. 

Once you hit submit, your information will be forwarded to our current Nurse. Our Nurse will schedule an appt. to speak with you and will then enter your information into our HIPAA compliant records system and help you with your concern. Please fill out the form below now


PLEASE COMPLETE THE FORM BELOW

If this is an emergency, please contact emergency personnel.
Name *
Name
Name of the Patient. Enter extra patient names in the comments section if necessary.
Birthdate *
Birthdate
pick one
Family Member 1
Family Member 1
Child/ Family Member
Birthdate
Birthdate
pick one
Family Member 2
Family Member 2
Child/ Family Member
Birthdate
Birthdate
pick one
Family Member 3
Family Member 3
Child/ Family Member
Birthdate
Birthdate
pick one
Phone
Phone
Preferred Form of Communication*
Please select all that apply
Please include other forms of communication if they would be preferable to you. Also include user names to any accounts you would like us to contact you through.
Address *
Address
Who is the patient? What happened? Where are you located? When did this happen? What events lead to this happening?

Disclaimer: This is not a substitute for medical advice. If you think you may have a medical emergency, call 911 or go to the nearest emergency room immediately.