Online Appointment Request

Please complete the form below to request an appointment at Rockdale Medical Center. A member of our pre-services team will call you within 24 hours Monday - Friday between 9 am - 5 pm to pre-register you and confirm your appointment. If you would prefer to call for an appointment please call 770-918-3707.

All fields with an asterick (*) are mandatory and must be completed in order for your request to be submitted. 

Patient First Name *  

Patient Last Name *  

Phone Number *  

Best time to call * 8 am to 10 am 10 am to 12 Noon 12 Noon to 2 pm 2 pm to 5 pm  

Patient Address *  

Patient City *  

Patient State *  

Patient Zip Code *  

Patient Date of Birth *  

Have you previously been a patient at Rockdale Medical Center?

Yes
No 

Preferred Day of Appointment * Monday Tuesday Wednesday Thursday Friday  

Preferred Time of Appointment * 8 am to 9 am 9 am to 10 am 10 am to 11 am 11 am to 12 Noon 12 Noon to 1 pm 1 pm to 2 pm 2 pm to 3 pm 3 pm to 4 pm 4 pm to 5 pm