If this is an emergency, call 9-1-1 or go to the closest ER.
This form is intended for non-emergency contact only.
Please provide your name.
First Name
Last Name
Please select from the following options
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About Your Bill
General Inquiry
Internships and Job Shadowing
Job Inquiry
Medical Records
Patient Portal
Speak to a Patient Advocate/File A Complaint
Sunflower Cafe
Share An Idea
Does your inquiry pertain to a specific NMC Health medical service or location?
Yes
No
Which NMC Health location/service are you inquiring about?
-- Select --
Emergency Department | NMC Health Campus
Family Medicine | Hesston
Family Medicine | North Amidon, Wichita
Family Medicine | Park City
Family Medicine | Valley Center
Home Care & Private Duty Services | NMC Health Campus
Immediate Care | Newton
Infusion Center | NMC Health Campus
Lab & Imaging | NMC Health Campus
Medical Unit | NMC Health Campus
Midwest Occupational Medicine | Park City
Neurology Specialists | NMC Health Campus
Orthopedics & Sports Specialists | NMC Health Campus
Physical Therapy & Rehabilitation | NMC Health Campus
Senior Behavioral Health Center | NMC Health Campus
Sleep Disorder Center | NMC Health Campus
Surgery Center | NMC Health Campus
Surgical Unit | NMC Health Campus
Wound Healing & Hyperbaric Center
Other
Are you asking for Patient Portal assistance for yourself or someone else?
Myself
Someone Else
Please provide your date of birth (MM/DD/YYYY).
Enter patient name and contact information
First Name
Last Name
Phone
Email Address
Please provide the patient's date of birth (MM/DD/YYYY).
Please provide the date or date range of the appointment(s).
What was the purpose of the appointment?
Please provide details about why you are contacting us.
How would you like to be contacted?
Phone Call
Email
Please provide a good email address.
Email Address
You are required to provide a phone number at which we can contact you.
Phone
I would like an email confirmation of my inquiry.
Yes
No
Enter your email address here
Email Address
I understand that this is a general contact form and a medical diagnosis cannot be determined from this communication. Information contained in this transmission will not be directly received by a physician and does not automatically create a patient-provider relationship. I further understand that communications submitted over the internet may not be secure and that I am voluntarily including any personal health information herein. I also give Newton Healthcare Corporation (doing business as NMC Health) permission to send any and all of my information to the proper contact to assist with my needs, and give NMC Health permission to contact me directly via email or phone in response to this submission. This form is only applicable to NMC Health locations and facilities.
I Agree
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