Request an Appointment

If you are interested in learning more or scheduling an appointment with a contienence or pelvic health care provider, please complete the form below. A member of our team will contact you as soon as possible.

Please note: We cannot process emergency requests from this form. If you are having a medical emergency, please call 911.

When you submit this form, your information will be sent to the appropriate Middlesex Health staff who will help you schedule an appointment or complete your request.

These requests are only monitored Monday-Friday during regular business hours. We do our best to respond to all patients in a timely manner. If you need immediate care, please visit one of our Urgent Care Centers or the Emergency Room.

All fields are required unless otherwise noted.

Are you a new or existing patient?
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Must be in 555-555-5555 format
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Let us know about the symptoms that bother you most. This will help us connect you with the right providers. (optional)
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Must be in mm/dd/yyyy format