Rine Medical Solutions

Schedule an Appointment

Choose your preferred method to schedule an appointment with us

Fill out our secure online appointment request form directly on our website.

Download our appointment form, fill it out at your convenience, and send it back to us.

Full Name *

Birth Date *

Address *

Sex *

Phone Number *

Email *

Social Security Number

Race

Ethnicity

Emergency Contact Phone

Emergency Contact Email

Relationship

Please describe the reason for your visit *

Doctor's Name *

Doctor's Phone *

Doctor's Address *

Preferred Pharmacy

Pharmacy Phone

Insurance Provider *

Policy Holder *

Group Number *

Policy Number *

Insurance Provider

Policy Holder

Group Number

Policy Number

Terms and Conditions *

You must read and agree to the terms and conditions before submitting.

You must read and accept Terms and Conditions before submitting your appointment