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Request an Appointment with the Clinic

Home > Request an Appointment with the Clinic

Request an Appointment with the Clinic

Please request an appointment online by completing and submitting the form below or contact us by phone to set your preferred appointment time.

First Name *

Last Name *

Address *

City *

State

Zip Code *

Phone Number *

Email Address *

Date of Birth *

Patient Status *

New

Existing

Type of Appointment *

Follow Up

New Problem (Please describe the problem)

Are you currently under the care of a physician?

Yes

No

Primary Care Physician Name

Insurance Type

So that we can serve you best, please answer a few questions. (Check all that apply) *

I have migraines, cluster headaches, or other headaches that have been diagnosed as other the neck origin

I have headaches that are not managed well with current medications

I have headaches that occur with or from medication changes

I have headaches that are keeping me from working, sleeping, or participating in normal activities

I have headaches that have required trips to the emergency room for treatment

I have headaches that feel like a hot poke in the eye or similar pain

I have pain when turning my head side to side or have a "catching" movement

I am experiencing muscle spasms or tighteness

I have pain that is aggravated by certain motions

I have headaches that are dull and achy

I have sensations of tightness or pressure across my forehead or on the sides and back of my head

I have tenderness on my scalp, neck, and shoulder muscles

I have headaches that are accompanied by blood pressure increases

I have headaches that I would describe as pulsating

Contact

Centra Health
1920 Atherholt Road
Lynchburg, VA 24501
434.200.3000 (Switchboard)

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