Synergy Care Connect

SYNERGY

CARE CONNECT

Appointment request

Tell us how to reach you

Please provide routing information only. Do not enter symptoms, diagnoses, medication history or other medical details.

First name *Last name *Email *Phone *State where you will receive care *Area of interest *Preferred contact method *Scheduling preference

I confirm that I am 18 years of age or older.I authorize Synergy Care Connect to use and share the contact and routing information in this request with an independent medical provider or medical group for appointment coordination. I understand that no clinician-patient relationship is created by submitting this form.

Do not include medical information in this request. A secure clinical intake will be provided separately if an appointment is available.