Request an Appointment

Please do not use this form if you have an urgent medical problem or you need to reschedule an existing appointment. Instead, call us at the Mainline Health Systems office you are scheduled to visit. After you submit your request, our appointment scheduler will respond within 48 hours. See below for forms to complete. Established patients may log in to the patient portal to request appointments and update forms.

Patient Registration Forms

Mainline Health in Southeastern Arkansas welcomes you to our practice. Once you have made your initial appointment, you may pre-register by downloading, printing, and completing the forms below. Please be sure to bring them with you to your first visit, along with any diagnostic films or other test results that may have been ordered or performed by another physician. Completing the forms prior to your visit will help speed up the new patient registration process.

Downloadable Forms:

• Patient Information Packet
• Provider Selection Form
• Provider Selection Form (Spanish)
• PPE History Form
• PPE Physical Examination Form
• PPE Medical Eligibility Form

Please note: It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.