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Student Health Center Appointment Request

To request an appointment, please complete the form below and click on "Submit". A representative will call you as soon as possible to schedule an appointment.

If you have any questions, comments or complaints about your appointment request, please contact us at (510)723-7625.

This service is for non-urgent appointments only. If you have a medical emergency, please call 911.

Patient Information

New Patient
Returning Patient
* Last Name:
* First Name:
* Date of Birth / /
(month/day/year - ex: 03/21/1975)
* "W" Number

Contact Information

* Daytime Phone:
Alternate Phone:
* Best time to call you back
(Between 9:30 am and 6:45 pm, Monday to Thursday)
* Email:


Preferred Contact Method:

Appointment Request Information

Preferred day or days for your appointment:
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred appointment time:
Morning
Evening

Briefly describe the reason for your visit:

Other Comments:

  
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Chabot-Las Positas Community College District
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Phone: (510) 723-6600