Request an Appointment (For established patients only)

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334.749.8121

NOTE FOR NEW PATIENTS: If you are a new patient and want to make an appointment with us please go to our website and click on the "NEW PATIENT SIGNUP" link. After we receive this information from you someone will call you to set up your appointment.

Patient Information

Child's First name

Child's Last name

Date of Birth

Name of person requesting appointment

Relationship to child - Parent/Legal Guardian

Cell Phone number

Email address

Check this box to confirm that your child is already an established patient of Pediatric Clinic

I would like to be seen TODAY

I would like to be seen at a FUTURE DATE

Requested Date, Time & Type of Appointment

If there's anything else that you would like me to know prior to your appointment, please include it here.

Your information will be encrypted.

Request an Appointment (For established patients only)

PLEASE FILL OUT ALL FIELDS COMPLETELY

Patient Information

PLEASE FILL OUT ALL FIELDS COMPLETELY

PEDIATRIC CLINIC LLC