Request an Appointment

Please tell us a bit about yourself and we will be in touch to set up an appointment.  

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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Have you ever been in the WIC program in Connecticut?
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Are you participating in other programs (SNAP, Cash Assistance, Husky A)?
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