Medical, Vision, Dental & Behavioral Health Services

To request an appointment, please select your preferred day of week and time frame. If an appointment is available that meets the criteria provided, you will receive a text confirmation that your appointment is scheduled.

At this time, we are not offering after-hours appointment.

Appointment

Appointment Type

Location

Preferred Day of Week

Select a Time

Are you a current patient of Clinica Sierra Vista?

Yes

No

Have you received the first dose of the Covid vaccine?

Yes

No

Demographics

First Name

Last Name

Social Security Number

Decline to Answer

Date of Birth

Gender

Email Address

Family Size

Household Income ($)

Decline to Answer

Income Frequency

Contact Number

Home

Work

Cell

Can You Accept Texts If You can’t be Reached by Phone?

Yes

No

State

City

Street Address

Zip

Primary Language

Marital Status

Ethnicity

Race

Are you a Veteran?

Yes

No

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

Employment Status

Homeless Status

Farm Worker Status

Insurance

Guarantor Name

Self

Date of Birth of Guarantor

Relationship to Patient

Primary Insurance Carrier

Not insured

Subscriber ID

Group Number (if Applicable)

Subscriber Name (First and Last)

Self

Subscriber Relationship

Documents

Submit supporting document

Supported Formats (.pdf,.png,.jpg); Max-Size: 3MB

Insurance Card (Optional)
Front Image (Supported Formats: (.pdf,.png,.jpg); Max-Size: 3MB)

Back Image (Supported Formats (.pdf,.png,.jpg); Max-Size: 3MB)

Declaration

I understand that by submitting this appointment request form I am only requesting an appointment and a Clinica Sierra Vista representative will call/text to discuss availability.

Appointment Request

Appointment

Demographics

Insurance

Documents