Hass Center | Request an Appointment

REQUEST AN APPOINTMENT AT THE DR.GERALD HASS CENTER

You may make an appointment by calling the department number directly, listed to the left, or by completing the form below. We will make every effort to respond to your appointment request as soon we receive it, within no more than 24-48 hours.

New patients are encouraged to print and fill out a Patient Profile for their first appointment. If you are an existing patient, you can use this form to change or update your information, including your address.

Appointments for Behavioral Health, CBFS, and Urgent Care are not available online. Please call the department directly to schedule an appointment.
 

 

Your Name*

Patient Name (If you are requesting an appointment for someone else.)

Relationship to Patient (If you are requesting an appointment for someone else.)

Patient Birth Date* (MM/DD/YYYY)

Are you a new or existing patient?*
New Existing 

Is the patient a student at Blackstone Innovation School?
Yes No 


Street Address:* Please include apartment or unit number.

City:*

State:*

Zip:*

Your Email*

Your Phone Number*


In which department would you like an appointment?*

If you are a new patient and unsure of which department to make an appointment in, please see our Services and Specialties for more information. If you are an existing patient, you can look up your provider and their department.

Type of appointment needed?*

Preferred Date(s)?

From:  
To:       

Preferred Time(s)?

Monday Tuesday Wednesday Thursday Friday
Morning
8 am - 11 am
 Morning  Morning  Morning  Morning  Morning
Afternoon
12 pm to 3 pm
 Afternoon  Afternoon  Afternoon  Afternoon
Evening
4 pm to 5:30 pm
 Evening  Evening  Evening  Evening  Evening


How did you hear about us?*

Additional Comments (optional)