Request an Appointment with Summit Healthcare Providers!
Appointment request form for SHMA. Please allow 48 business hours to be contacted. SHMA staff will attempt to contact you 3 times, after that your form will be archived and a new form will need to be submitted or call 928-537-6700 to make an appointment.
What type of healthcare provider would you like to schedule an appointment?
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Cardiology
Ear, Nose & Throat (ENT)
Family Medicine
General Surgery
Internal Medicine
Obstetrics/Gynecology
Orthpedics
Pain Management
Plastic & Reconstructive Surgery
Pediatrics
Pulmonology
Urology
Not Sure
What is the reason for your appointment?
Date of Birth
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Month
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Day
Year
Date
Patient's Full Legal Name
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First Name
Last Name
Guardian's Full Legal Name (for patients 18 and under, type N/A if not applicable)
First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone
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Area Code
Phone Number
E-mail
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What days work best for you?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What time works best for you?
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Morning
Afternoon
Evening
Any specific date/time?
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Month
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Day
Year
Date
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Minutes
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AM/PM Option
I would like to be notified about promotional services. Please note that we do not rent or sell your information to any third parties!
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Yes
No
PLEASE READ THE FOLLOWING TERMS OF USE BEFORE USING THE SUMMIT HEALTHCARE ASSOCIATION ONLINE APPOINTMENT REQUEST FORM.
IF THIS IS A MEDICAL EMERGENCY, PLEASE IMMEDIATELY CALL 911 FOR PROMPT MEDICAL ATTENTION. DO NOT RELY ON ELECTRONIC COMMUNICATIONS FOR ASSISTANCE IN REGARD TO YOUR IMMEDIATE, URGENT MEDICAL NEEDS. THE ONLINE APPOINTMENT REQUEST FORM IS NOT MONITORED FOR PURPOSES OF RESPONDING TO EMERGENCIES.Summit Healthcare Association takes your privacy very seriously. Please refer to our website Terms of Service and Terms of Use, as well as our Notice of Privacy Practices for more information. Our Notice of Privacy Practices describes our use and disclosure of protected health information, and the steps we take to safeguard your protected health information.The Summit Healthcare Association website is designed and created by Advice Media. The website maintains a current security certificate, which means information you send or receive through the website is private. Nevertheless, in rare instances, security protocols could fail, causing a breach of privacy and/or security of protected health information. IN NO EVENT WILL SUMMIT HEALTHCARE ASSOCIATION, ITS AFFILIATES, SERVICE PROVIDERS, EMPLOYEES, AGENTS, OFFICERS OR DIRECTORS BE LIABLE FOR DAMAGES OF ANY KIND, ARISING OUT OF OR IN CONNECTION WITH YOUR USE, OR INABILITY TO USE, THE ONLINE APPOINTMENT REQUEST FORM, INCLUDING ANY DIRECT, INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE DAMAGES, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURY, PAIN AND SUFFERING, EMOTIONAL DISTRESS, LOSS OF REVENUE, LOSS OF PROFITS, LOSS OF BUSINESS OR ANTICIPATED SAVINGS, LOSS OF USE, LOSS OF GOODWILL, LOSS OF DATA, AND WHETHER CAUSED BY TORT (INCLUDING NEGLIGENCE), BREACH OF CONTRACT OR OTHERWISE, EVEN IF FORESEEABLE.THE FOREGOING DOES NOT AFFECT ANY LIABILITY WHICH CANNOT BE EXCLUDED OR LIMITED UNDER APPLICABLE LAW.The personal information collected by using the online appointment request form consists of name, address, phone number, email address, and date of birth. By utilizing our online appointment request form, you specifically consent to the use of this information to facilitate an appointment with a Summit Healthcare Association provider. If you do not want us to use your information as stated in this disclaimer or our Privacy Practices, please do not use the online appointment request form.
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