Palm Beach Pediatrics | Appointment Request

Schedule your next appointment at Palm Beach Pediatrics online!

Simply complete the form below and a member of our customer service team, at your preference, will call or e-mail you a confirmation of your next appointment.

Unfortunately, due to the nature of the some appointments, the following situations cannot be scheduled online and must be made by calling one of our offices:

Children 0 - 2 months of age
All same day sick visits
Injury
Pre-Op Clearance
ADHD / ADD
Asthma

As always, in the event of an emergency, dial 911 immediately.

ALL INFORMATION ON THE FORM BELOW MUST BE COMPLETED IN ORDER TO PROCESS YOUR REQUEST PROMPTLY.

Please select the office where you would like the appointment:


Name:
Birthdate:
Sex:	Male Female
New or Existing Patient?	Existing Patient New Patient


Name:
Birthdate:
Telephone Number:
E-Mail Address:
Preferred method of contact for confirmation:	E-Mail Telephone


Please select your insurance company:
Plan Group Number:
Plan ID Number:
Address (from back of insurance card):

City, State, Zip:


Preferred Provider:
Preferred Appointment Date:
Preferred Appointment Time:


Notes / Comments: