Request an Appointment

This is not an appointment or cancelation confirmation.

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.

If this is an emergency, please call 911.

Select a Type of Request:(Required)

Name(Required)

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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:(Required)

Select a service:(Required)

Insurance Information:

Name of Medical Insurance:

Policy #:

Message to NCHC:

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

Consent(Required)

I agree to provide the information entered in this form to 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.