Request An Appointment | Parekh Medical Clinic

Important Note: This request goes directly to our Administration Office and someone will contact you to complete your request the same day.

Are you a current patient of Parekh Medical Clinic?*

If you are a current patient at Parekh Medical, please visit the "Patient Portal" to complete your appointment request.

[Patient Portal Login]

Important Note: Please provide the information below.

If you prefer that we contact you directly to discuss an appointment at our clinic, please call the following:
Vanessa L. White
Clinic Administrator - Parekh Medical Clinic
Email: [email protected]
Office: 662-562-8278

Patient Name:*

Prefix First Last Suffix

PLEASE ENTER THE GUARANTOR NAME IF DIFFERENT FROM PATIENT

Date of Birth:*

Address:*

Street Address City State ZIP Code

Best Phone Number To Reach You To Confirm:*

Do You Have Insurance?*

Name of Insurance Provider:*

Insurance ID Number:*

Do You Have A Preference on Providers?*

Name of Preferred Provider:*