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Please note: We cannot process emergency requests through this form. If you are experiencing a medical emergency, please call 9-1-1.

This form cannot be used to schedule same-day appointments. For same-day appointments please call the office directly, for practice and provider numbers please visit our full directory listing.

Please complete the form below if you have been seen at Akron General in the last 3 years.

Patient refers to the person who will be seeing the medical professional.

Fields with an asterisk (*) are required
Requester Information
Basic Patient Information
Additional Patient Information
Patient Contact Information
Appointment Confirmation

*Akron General will make every effort to confirm appointments scheduled online and send appointment reminders via your preferred method

Emergency Contact Information
Appointment Details
Have you been a patient previously?
Referral Information
Were you referred to us?
Specialist and Preferred Practice Information
Preferred Appointment Day and Time
Other Appointment Information
Is this a work related injury?
Insurance Information
Does this patient have health insurance?
Subscription Information
Mail Claims Information
Subscriber Information
Subscription Information
Mail Claims Information
Subscriber Information
So That We Can Serve You Better
Language Needs
Hearing Impaired Needs
How Did You Hear About Us?
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