Appointment Request

This service is not intended for emergencies. If you are experiencing a medical emergency call 911.

To request an appointment with a physician or for a test/procedure, please complete the form below. Please be advised after completion of this form, your appointment is not confirmed. A CentraState representative will contact you within 1-2 business days regarding your request.

  • You can also request an appointment with a physician by calling 866-CENTRA7 Monday – Friday, 8:30am – 4:30pm. 
  • You can schedule an appointment or pre-register for tests and procedures by calling 732-294-2778, Monday – Friday, 8am to 7pm.
*First name:
*Last name:
*Date of Birth:
   MM/DD/YYYY
*Address:
Address 2:
*Zip:
*Phone number:
*Email:
*How did you hear about us?
Comments (please specify appointment type and preferred physician if applicable):