Request an LGBTQ Appointment at UnityPoint Clinic

Request an Appointment

Compassionate health care in a comfortable environment is our goal. To request an appointment, please fill out this form and a representative from our team will contact you within three (3) business days or sooner.

Notice: Please do not use this form for urgent medical issues, same-day appointments or appointment cancellations. If this is a medical emergency, please call 9-1-1.

Preferred Name:*Legal First Name: *Legal Last Name: *Date of brith (MM/DD/YYYY): *Pronouns: Preferred Provider:Preferred Appointment Date (MM/DD):Appointments available between 5-7 p.m. on the first and third Wednesday of each monthEmail:*Phone Number: