Request an Appointment with First Person Care Clinic

Please use the online form to request an appointment with First Person Care Clinic.
* = Required Information

Name Name * First Last
How do you prefer to be contacted? *
Type of Appointment *
Type of Appointment
(Other) *
Phone Phone * - ### - ### ####
Best time to call? *
Email *
Fax Fax - ### - ### ####
Preferred Appointment Time *
Do you have health insurance? *

Do you have health insurance? Yes No
Attach a picture of your Drivers License / ID Card:
Upload a File

Attach Files
Attach a picture of your Health Insurance Card:
(Front Of Card)
Upload a File

Attach Files
Attach a picture of your Health Insurance Card:
(Back Of Card)
Upload a File

Attach Files
Payment Options *

Payment Options I am a Self-pay patient Sliding Scale Option
Comments
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
We will contact you shortly from Phone # 702-380-8118

Please add us to your Contacts so you will recognize our calls from our scheduling team.