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info@masihausa.org

812-962-7353

MASIHA Free Specialty Clinic

"Serving humanity with diversity...one patient at a time"

Refer A Patient or Request Appointment

Please fill out the following form
in order to make a specialist referral or request an appointment.

Patients First Name

Patients Last Name

Email

Patients Date of Birth

Phone

Please Pick A Specialty

If you answered yes to any question, please elaborate

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for referring this patient. We will get back to you soon !

Our office hours are

Monday to Thursday 9:00 am to 5:00 Pm,

(Lunch from 12 pm to 1 pm)

Friday & Saturday 9:00 am to 12:00 pm.

812-962-7353

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