Contact Utica Park Clinic

Request an Appointment

Please complete the form below to request an appointment. We will confirm your request within one business day. For prescription refills, please call your provider's office.

If you are experiencing a medical emergency, call 9-1-1 immediately.

For more information on the specialties or services offered by Utica Park Clinic, click here.

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Would you like to request an appointment with a health care provider? *

Yes

First Name *

Last Name *

Address *

Address 2 *

City *

State *

Zip Code *

Phone Number *

Email Address *

Date of Birth *

Month

Day

Year

Your Gender *

Insurance Provider *

Have you been seen by a Utica Park Clinic provider in the last two years? *

Service Requested *

Preferred Clinic Location

Appointment Date Requested

Month

Day

Year

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