Request a New Patient Appointment

Thank you for your interest in becoming a patient at Nova Wellness Center.
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Please complete the form below and briefly describe the health concerns or services for which you are seeking assistance. Before scheduling your first appointment, a member of our staff will contact you by phone or email to gather additional information and confirm that our clinic can provide the care you need.
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Please do not include detailed medical records, highly sensitive health information, or urgent medical concerns in this form. Submitting this form does not establish a physician-patient relationship or guarantee acceptance into the practice.
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If you are experiencing a medical emergency, call 911 or seek care at the nearest emergency department.
Please provide the following information: 
  • Full name
  • Date of birth
  • Phone number
  • Email address
  • Preferred method of contact
  • Best time to reach you
  • What health concerns or services are you seeking assistance with?
  • How did you hear about our clinic?
By submitting this form, I authorize Nova Wellness staff to contact me by phone, voicemail, text message, or email regarding my request for care. I understand that standard email and text messaging may not be completely secure and that submitting this form does not establish a physician-patient relationship.