Billings Clinic  
Especially For:

Callback Request

Appointment Request

Please fill out the form below.  A HealthLine nurse will call you between the hours of 9:00 am to 8:00 pm. If this is an emergency dial 911 on your telephone.

If you would like to speak with a Healthline nurse directly about a physician referral please call 406-255-8400 or 1-800-252-1246.
(Note, required fields are in red)

Title: Mr.  Ms.  Mrs. 
First Name:   *Required
Last Name:   *Required
Date of Birth:     *Required
Home Phone: ( )  - *Required

May we leave a message? Yes No
Work Phone: ( )  -  Ext:
Email: *Required
What day and time would you like to request an appointment?  We will do our best to find a time that works for you, but cannot guarantee the time you have requested. (M-F 8:00 am-5:00 pm)

Day:
Time: :
Physician Name: *Required
Reason for Appointment: (Please do not include personal health information)

General Comments:  (If you have a question involving personal information, please call 406-255-8400 or 1-800-252-1246.)

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801 N. 29th Street  |  P.O. Box 37000  |  Billings, Montana 59107  |  406.238.2500
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