Book An Appointment Patient Name * First Name Last Name Phone * (###) ### #### Consent To Text? By checking this box 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 Date Of Birth (Age 18+) MM DD YYYY Are you a new patient Yes No Address * Zip Code * Race Gender Male Female Email Referral Source Advertising Patient in Practice Word of Mouth Internet search Other Chronic Conditions * Reason for Visit * Thank you for submitting your appointment request form. Someone will reach out to you within 24 to 48 hours.
