Call 844-518-3627
Call 844-518-3627

Appointment Request

If this is an emergency, please call 911 immediately.

Please complete the form below to submit a request for an appointment with an Ellis Medicine affiliated provider. After you submit a request, you will receive a phone call within 24 hours to confirm your information and schedule the appointment. 

(Requests submitted on weekends or holidays will be addressed the next business day)

Specialty Area


Patient Information

Have you been seen at Ellis Medicine in the past?

Do you have a diagnosis?

Appointment Details

Reason For Appointment

Date Preference

We will make every effort to accommodate your date and time preferences. If a date or time isn’t available, we will work with you to find the next available appointment.

Time Preference

Additional Information

Yes, I would you like to receive health-related emails from Ellis Medicine