Roanoke Clinic Office Phone: 252.537.9176

Hours of Operation: M - F  7am - 5pm

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Small Business Health Options
  1. Use the form to submit your Small Business Health Options inquiries. If this is a legal or personal inquiry, please browse back to the home page and click the button corresponding to your inquiry.
  2. Salutation(*)
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  3. First Name(*)
    Please type your first name.
  4. Last Name(*)
    Please type your last name.
  5. Title(*)
    Please specify your Title in the firm
  6. Company Name(*)
    Please type your company name.
  7. Company Address(*)
    Please type your street address.
  8. City(*)
    Please type your city.
  9. State Abbreviation(*)
    Please type your state.
  10. Zip Code(*)
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  11. Employee Count(*)
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  12. Current Health Insurance (*)
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    Write the name of your health insurance carrier or write NONE if applicable.
  13. Est. Monthly Expense(*)
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    Format $XX,XXX.xx
  14. E-mail(*)
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  15. Company Phone(*)
    Please type your company phone including dashes.
    XXX-XXX-XXXX (please include dashes)
  16. Phone Extension
    Please type your phone extension if any.
    XXXX
  17. Personal Cellphone(*)
    Please type your cellphone including dashes.
    XXX-XXX-XXXX (please include dashes)
  18. After completing your contact information, a second page of the form will appear for you to discuss the issue and note your desired contact time and method.
  19.  
  1. Describe your interest or concern
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  2. How best to contact?
  3. 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.
  4. Contact no later than(*)
    Please select a date when we should contact you.
  5. Best Time To Contact by Phone






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  6. Captcha Verification
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Roanoke Clinic, Roanoke Rapids, NC

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