Reproductive Health Appointment Request- Midland County Department of Public Health

Use this form to request an appointment with the Reproductive Health Clinic (Family Planning and/or Sexual Health) at the Midland County Department of Public Health (MCDPH).

Appointment requests will be reviewed during normal clinic hours (Monday-Friday 8am-5pm), and we will contact you to schedule an appointment.

If you are experiencing a medical emergency, call 911 or proceed to the nearest emergency room.

This form is secure and HIPAA-compliant. Please provide as much detail as possible.

1. What is your legal name? *This question is required.

First Name
Last Name

2. What is your preferred name?

3. What is your date of birth? MM/DD/YYYY *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

4. Birth Sex? *This question is required.

5. Gender Identity?

Please enter an 'other' value for this selection.

6. Preferred Pronouns?

Please enter an 'other' value for this selection.

7. Tell us how we can help you (select all that apply): *This question is required.

I have genital symptoms and need to be tested for infection (may include a urine specimen and/or vaginal swab).
I am interested in starting a birth control method.
I think I am pregnant.
I am not having genital symptoms, but I would like testing for sexually transmitted infections.
I need to refill my birth control prescription (confidential appointments for ages 13 and over).
I need a pap smear (cervical cancer screening due over age of 21).
I have a breast concern.
I need an annual exam (which is not a cervical cancer screening).
Other - Write In Please enter an 'other' value for this selection.

8. What day of the week works best for you (select all that apply):
Note- All services may not be available on all days of the week. *This question is required.

9. What time of day works best for you (select all that apply): *This question is required.

10. Do you have medical insurance? *This question is required.

11. When we contact you to schedule an appointment, how may we contact you? *This question is required.

Phone call
Text- Please note, this is not a confidential method of communication, so no personal information will be sent aside from an appointment day/time.
E-mail- Please note, this is not a confidential method of communication, so no personal information will be sent aside from an appointment day/time.
Current client registered in Patient Portal

12. What is your phone number? *This question is required.

13. What is your e-mail address? *This question is required.

14. What is your address?

Street Address
City
State
Zip Code

15. Is there anything else you would like us to know?