Appointments Form | Emmanuel Project

Patient Name *

Date of Birth *

Phone *

Patient or Parent Email Address *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Parent Name (scheduling a child)

Monthly Events
1st Thursday	LAM (Lake Area Ministries) 4:00p – 6:30p 131 NE Commercial Cir, Keystone Heights, FL 32656
1st Friday	Melrose Center 9:00a – 1:30p 307 FL-26 Melrose, FL 32666
2nd Saturday	Ace Foundation 9:00a – 12:00p 6444 Beach Blvd. Jacksonville, FL 32216
3rd Saturday	Impact Clay Train 10:00a – 12:00p
Rotating every 4th month	Clay Hill Elementary School (June, October) 6345 Co Rd 218, Jacksonville, FL 32234 Grove Park Elementary (July, November) 1643 Miller St., Orange Park, FL 32073 Providing Back-to-School Clinic Green Cove Springs Junior High (August, December) 1220 Bonaventure Ave. Green Cove Springs, FL 32043 Keystone Heights High School (May, September, January) 900 Orchard Ave. Keystone Heights, FL 32656
4th Monday	Mission House 2:00p – 4:30p 800 Shetter Ave. Jacksonville Beach, FL 32250
4th Wednesday	Ace Foundation 5:00p – 7:30p 6444 Beach Blvd. Jacksonville, FL 32216

Preferred Clinic Location *

Preferred Clinic Date *

Month *

Day *

Year *

Reason for Visit

Once we receive your request, you will be scheduled, receive an email within 24 hours to confirm the appointment and ask follow up questions we may have.

All patient information is strictly confidential, and adheres to all HIPAA guidelines

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