Please complete the form below to request an appointment. We will confirm your request within one business day. For prescription refills, please call your provider's office.

If you are experiencing a medical emergency, call 911 immediately.

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* Contact Information

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* Date of Birth

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* Gender

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* Have you been seen by a Utica Park Clinic provider within the last two years?

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* Appointment Date Requested

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* Message|Additional Comments

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