This online form is not to be used in the case of an emergency. If you are experiencing a medical emergency, please call 911.

Once your form is submitted, a Patient Access Specialist will contact you within two (2) business days to schedule your appointment.

If you need an appointment sooner, or the provider specialty is not listed, please contact us at 1.800.8.COOPER (1.800.826.6737) to speak with a Patient Access Specialist who will be happy to assist you.