Appointments

New Patients

Schedule An Appointment

We offer state-of-the-art treatment for patients who have rheumatoid arthritis, lupus,
osteoarthritis, and many other autoimmune diseases, as well as osteoporosis.

New Patient Appointment Request

All fields marked with * are required.

This form must be completed in it’s entirety in one sitting. If you leave the form while working on it, it may time out for security reasons and you will lose all of your progress. Please allow yourself the time to complete this form when you are unlikely to be interrupted. Thank you!

Please select one of the following:*
- Adult
- Child
Referred By:*
Are you or any of your relatives currently treated by (or have been treated in the past by) a Kirksville Specialty Clinic provider?*
- Yes
- No
Name of person completing form and relationship to patient:*
Patient Name:*
DOB:*
MM slash DD slash YYYY
Age:*
If patient is a minor, please list parents marital status:*
Home Phone:*
Mobile Phone:*
Email:*
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Reason for Appointment*
Current medications and dosage (please list all prescription medications you are taking, including over-the-counter and supplements):*
Do you have insurance? Kirksville Specialty Clinic is contracted with the following insurance carriers: AARP, Aetna, Americo, BCBS, Care Improvement Plus. Cigna. Combined Insurance Company of America, Companion Life, and Coventry Health Care. If you have coverage with any of these insurers, please provide the following:*
- Yes
- No
Copy of Insurance Card
Max. file size: 64 MB.

New Patients

Schedule An Appointment

We offer state-of-the-art treatment for patients who have rheumatoid arthritis, lupus, osteoarthritis, and many other autoimmune diseases, as well as osteoporosis.

New Patient Appointment Request

We offer state-of-the-art treatment for patients who have rheumatoid arthritis, lupus,
osteoarthritis, and many other autoimmune diseases, as well as osteoporosis.