Patient Request Form
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Thank you so much for requesting care at the Musculoskeletal Student Clinic! Services we provide are care for muscle and bone injury/pain, as well as sports participation physicals for children! Eligible patients include those who are uninsured, underinsured, and/or 200% below the poverty level. We operate on the last Monday of every month from 5-8pm at Centro Médico (904 Merry Street Augusta, GA 30904). Please fill out the following form, and we will contact you confirming your appointment. 

If you have any questions, please contact us at mskstudentclinic@gmail.com or 706-250-2582.
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Name
Phone Number
Date of Birth
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DD
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Sex/Gender
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What is your muscle/bone-related issue?
What day do you prefer to have your appointment?
How did you hear about us?
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