Complete appointment request form

Before appointments can be scheduled, you'll need to fill out our appointment request form. This information is crucial for customizing care with the appropriate clinics and specialists. The form is available online to complete at your convenience. 

If you need assistance with the form, you are welcome to call our team for guidance at 205-934-5471.

Appointment Request Form

Referral from provider

Your primary care provider can also start this process by sending an EPSDT referral or the Referral Form below. They can fax referrals and most recent visit notes to us at 205-638-2526. We will have to request a referral from your provider closer to the appointment to bill insurance for services.

Referral Form

Additional Resources

Send us any prior testing that has been completed. If the person who has custody is not the biological parent, please send proof of legal guardianship. We cannot communicate with you about appointments without this document.

Appointment Scheduling and Waitlist

Please be aware that our wait-times are currently 8-12 months for appointments.

Once we receive your completed appointment request form, we'll review the submitted information. Civitan-Sparks Clinics will then contact you to set up your appointment(s). Our team will work with you to find convenient dates and times for your visits.