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Type of visit

Doctors/Practice Name

Doctors Phone Number

Reason for visit

Is this your first visit?

Note; Availability, etc

Desired Appointment Date

Alternate Date for Visit

Preferred Time of Day


Check the Health condition that apply to you.

ArthritisAsmthmaHeart DiseaseCongestive Heart FailureHeart Bypass SurgeryDepressionDiabetes Type IDiabetes Type IIChronic Heart Burn/GERDHigh CholesterolHigh Blood pressureIrritable Bowel DiseaseLower Back or Neck PainHeart AttackAIDS/HIVNone of the Above

Current medications.(required)

Disclaimer: Though we provide the network, Trinity HealthShare is not responsible for the services rendered by any of the providers listed above. Additionally, we do not guarantee that ALL services rendered at the above facilities will be eligible for sharing under your plan. Please check your Member Guidebook for more details on the services that are eligible under your plan and have your provider call in prior to your visit.