• Request for Appointment

      • This form may not be completed by minors (under 18 years old).
      • Parents or legal guardians may complete the form for their minor children.
      • Adults (over 18 years old) may not complete the form for any other adults, unless the completer of the form has power of attorney or legal medical guardianship for the adult.
      • After you submit this form, the SLBMI Intake Department will be in contact with you within 24-business hours. To respect your privacy, the Intake Department will try to reach you no more than two times without response.
      • We accept most major insurance companies, but we do not accept Medicaid Primary and Ambetter.

    Do not use this form if you have a medical emergency or urgent problem. Instead, please call us at 314-289-9411, or if you need immediate medical assistance, contact 911 or seek the nearest emergency room.

    Please note that all fields marked with an asterisk (*) are required.

    • Patient Information

    • Date Format: MM slash DD slash YYYY
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