Primary Care of the Brookfields

Please fill out the form below to contact Primary Care of the Brookfields.

If you wish to become a patient, please send inquiry here and include your date of birth.

Please do not send time sensitive questions or questions about your medical condition. 

Name *
Date of Birth (for enrollment inquiries)
E-mail *
Street Address *
City *
State
Preferred Telephone *
How did you find us?
Message *

 

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.

 

Please allow 72 hours for reply. Please contact office or provider for appointment or urgent matters. 

 

The information you provide will be used to communicate with you directly to discuss services and enrollment including creation of a patient portal page for ongoing services only if you enroll. We do not sell your information to any 3rd party. If insurance is utilized for services, your Protected Health Information (PHI) will be disclosed following HIPAA guidelines. By providing this information, you agree to the collection and use of information in accordance with this Privacy Policy.