Primary Care Online Patient Message
PLEASE DO NOT USE THIS FORM IF YOU ARE EXPERIENCING SYMPTOMS SUCH AS SHORTNESS OF BREATH, CHEST PAIN, SEVERE BLEEDING, SEVERE WEAKNESS ON ONE SIDE OR SLURRED SPEECH! PLEASE SEEK IMMEDIATE MEDICAL ATTENTION BY CALLING 911.
If you have not received a phone call from the Primary Care office within 4 hours of submitting a request, please call our office at 252-451-3200. Please do not send more than one message per patient within 24 hours. All submissions regarding prescription refills, forms or basic information should receive a response within 24 to 48 hours by phone.
YOU WILL NOT RECEIVE AN ELECTRONIC RESPONSE FROM ANY BWC STAFF!
Complete the fields below and submit your message.
Date:
*Patient Name: *DOB:
*Phone Number:
Name & Relationship to Patient:
Patient's Physician: Browder, David Chamberlain, Matthew Chesnutt, Martha Cohen, Michael Gibson, Teresa Hood, Martin Pico, Aaron
Patient Allergies:
Pharmacy:
Please check any of the below symptoms you may be experiencing:
Fever
Pain
Nausea/Vomiting/Diarrhea
Congestion/Cough/Runny/Stuffy Nose
Urinary Symptoms
Swelling
Unusal Headache
Other:
Medication Refills
Request Appointment
Miscellaneous/Forms
Describe needs and/or symptoms:
Boice-Willis Clinic Primary Care is not responsible for any submission not received due to firewalls, antivirus programs or other technical difficulties. If you have not received a response regarding a sick patient within 4 hours, please contact our office by phone at 252-451-3200. Please note this form should be submitted during normal business hours only. If you need to speak to a physician or nurse after hours, please refer to our after hours contact information by clicking here.