Appointment Request Form - Lexington Pediatrics, PC

Well Appointment Request Form

NOTE FOR NEW PATIENTS: You need to FIRST REGISTER before you can request an appointment by use of this form. See Joining Our Practice. : Please provide all immunization records to our office prior to booking your first well-child visit. If we are unable to review your records prior to your appointment, you may need to schedule another appointment. NOTE FOR PATIENTS GOING TO COLLEGE: All college forms need to have the college students information completed then forwarded to us for completion before their scheduled physical. Please allow 2-3 weeks for the form to be completed.
Patient Information

(mm/dd/yyyy)

Parent/Guarantor Information

Desired Appointment Information

	Note: Summer physicals need to be scheduled 3 months in advance. All physicals scheduled between 9:00a.m. and 2:45p.m. can be booked up to six months in advance. Physicals needed after 3:00p.m. can only be scheduled three months in advance.
		Select the best day(s) and times for you below and we will do our best to accommodate your requests.

9-10:15a	10:30-11:45a	1-2:45p	3-4:45p



Enter the characters you see below and click SUBMIT.

INSTRUCTIONS

New patients need to first register before they can use this form.

Existing patients can use this form to request a future non-urgent medical appointment.
"*" shaded fields are required.

We will contact you by phone or email (if provided) to confirm your appointment.

After you have entered your information into this form, please click PRINT on your browser if you would like to copy this page for your records.

Hit SUBMIT when you are finished.

KNOW MORE

When you are completing our online forms, items marked with an "*" are required fields. Make sure you enter your information into all fields that are marked with an asterisk.