Roanoke Clinic Office Phone: 252.537.9176

Hours of Operation: M - F  7am - 5pm

Health & Prospective Patient Inquiries
  1. NOTICE: Do NOT provide personal, sensitive medical information. This form is for general medical information inquiries only. No specific professional medical advice will be given unless accompanied by an official patient visit at Roanoke Clinic. This form is not certified for HIPAA communication of protected medical information. The submitter of form assumes all responsibility for information contained within.
  2. Salutation(*)
    Invalid Input
  3. First Name(*)
    Please type your first name.
  4. Last Name(*)
    Please type your last name.
  5. Address(*)
    Please type your street address.
  6. City(*)
    Please type your city.
  7. State Abbreviation(*)
    Please type your state.
  8. Zip Code(*)
    Invalid Input
  9. Current Health Insurance (*)
    Invalid Input. Write the name of the company or write none.
    Write the name of your health insurance carrier or write NONE if applicable.
  10. Employer Name(*)
    Please type your company name.
  11. E-mail(*)
    Invalid email address.
  12. Personal Cellphone(*)
    Please type your cellphone including dashes.
    XXX-XXX-XXXX (please include dashes)
  13. Describe your interest or concern
    Invalid Input
  14. How best to contact?
  15. Please allow ten business days for Dr. Rupe to be able to respond. Please indicate your latest contact date with the calendar below. Cellphone numbers receive quickest response.
  16. Contact no later than(*)
    Please select a date when we should contact you.
  17. Best Time To Contact by Phone


    Invalid Input
  18. Captcha Verification
    Invalid Input
  19.   
Roanoke Clinic, Roanoke Rapids, NC

View Larger Map
Click on the box in the left-hand corner for an expanded map view.