Request An Appointment Patient Name * First Name Last Name Phone * (###) ### #### Consent To Text? * By checking this yes you agree to receive SMS messages from Cleveland Ibn Sina Free Clinic related to appointment reminders, health updates, and clinic announcements. You may reply STOP to opt-out at any time. Reply to HELP to (440) 644-0511 for assistance. Message and data rates may apply. Message frequency will vary. To learn more about our Privacy Policy and Terms & Conditions please visit https://www.clevelandibnsina.com/privacy-policy Yes No Date Of Birth * MM DD YYYY Are you a new patient Yes No Address * Zip Code * Race/Ethnicity * African American/Black Hispanic/Latino Native American/Indigenous Pacific Islander Middle Eastern/North African White/Caucasian Other (Specify in text below) Prefer Not to Say Specify Other (From Above) Gender Male Female Email Referral Source Advertising Patient in Practice Word of Mouth Internet search Other Chronic Conditions * Reason for Visit * Requested Specialties * Primary Care/Internal Medicine Pulmonology Cardiology Neurology Podiatry Allergy & Immunology Endocrinology Psychiatry Pediatrics Thank you for submitting your appointment request form. Someone will reach out to you within 24 to 48 hours.
