Schedule Consultation

Clinician's Name * Required
First Last
I am a School Based Health Center Provider who has enrolled with Illinois DocAssist
- Yes
- No
Speciality * Required
Practice Type * Required
Practice Type, Other
Name of Facility/Practice * Required
Facility/Practice Address * Required
Street Address Address Line 2 City State ZIP Code
Best phone number for consultant to call you back * Required
Best time for Consultation * Required

(Example: 1 PM -3 PM Tuesday, June 6th)
Email * Required
Enter Email Confirm Email

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