Request an Appointment – Norwalk Community Health Center

By submitting this form, I consent that the information provided is accurate and can be used by Norwalk Community Health Center (NCHC) to contact me. I understand that this is not an appointment confirmation, or appointment cancelation.

This form is for non-urgent requests only. Do not use this form if you need an urgent visit, are pregnant, have severe pain, have had a recent accident or trauma, require prescription or refill of a controlled substance, have a psychiatric emergency, or you think you have a medical emergency.

Instead call your doctor or 911 immediately.

A NCHC staff member will contact you to verify the information submitted.

Hours of operation for NCHC are Mon-Fri 8:00-5:00 and Saturday 8:00-12:00.
Calls will be returned during our normal business hours.

Select a Type of Request:(Required)

Name(Required)

First Last

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone# for NCHC to Contact:(Required)

Email:(Required)

Enter Email Confirm Email

Select a location:

Select a service:

Insurance Information:

Name of Medical Insurance:

Policy #:

Message to NCHC:

Anything you would like our representatives to know before contacting you?