Sentara Medical Group New Patient Appointment Request
Thank you for requesting an appointment with a Sentara Medical Group physician. Your needs will be reviewed and someone will be in contact with you as soon as possible to schedule your first appointment. If you have an urgent medical need, please visit an urgent care facility or emergency department.

(*)Indicates Required Field
First Name:*
Last Name:*
Daytime Phone:* (xxx-xxx-xxxx)
Email:* (We will keep your email completely private)
How would you like us to contact you?*
What time of day is best for us to reach you?*
Zip Code:*
Date of Birth:* (mm/dd/yyyy)
Insurance Provider:*
Type of Physician Needed:
If you know the name of the physician you would like an appointment with, please insert the physician's name below:
Preferred Day and Time of Appointment:*
I would like to receive information from Sentara in the future: