BEAUMONT HEALTH & WELLNESS

For an emergency, call 911

This form may be used to request a routine (i.e. non-urgent) appointment at Beaumont Health & Wellness Clinic

You will be contacted BY PHONE, usually the same day we receive your email, to schedule your appointment. If your medical need is urgent (but non-emergency), call your physician’s office directly or visit our Beaumont Health & Wellness Clinic .

	Comments:
	Please enter your contact information:
	Patient Name:
	Parent or Guardian (if patient is a minor):
	Patient's Date of Birth:	/ / ( i.e. mm / dd / yyyy )
	Preferred time of day to be called:
	Phone number where you can be reached:
	Your Email Address: