Appointment Requests
 
 
 

 

Use this form to request routine health maintenance (check-up) appointments only.

We'll try to respond to your request as soon as possible. If you don't hear from us within a few days, please call.

If you need an appointment for an illness or follow-up of an illness, please call the office.  

 

This information is communicated to us via secure e-mail. If you use e-mail to communicate with one of us, you agree to the following:

1. Secure e-mail is not 100% secure.

2. Employers may view e-mail sent using their work-provided e-mail system.

3. E-mail should not be used for emergencies or time-sensitive issues.

4. If a response is not timely, you should call the office.

5. You should keep a copy of the e-mail you receive from us. 

6. We may keep a copy of the e-mail that we send you.

Please call us if you have any questions about these statements. Thank You.

 

Who would you like your appointment with?







-C

When would you like the appointment?

Which office would you like to come to?

What day of the week would you like the appointment?
(Please choose more than one day if you would like. )

What time of day would you like the appointment?
(Please choose more than one time slot if you would like.)

How should we confirm your appointment?

Email :

Phone :

Address :

Are you a new patient to the practice? If you're a new patient, please make sure you register first using this web site.



Other family member already registered in practice?

Special Instructions?

Please complete the follow:

Child's Name:
Child's Date of Birth:
Your Address:
Your Telephone Number: Home #:

Work #:

 
 
     
 

617.361.1470     fax 617.361.9060
695 Truman Pkwy, Hyde Park, MA 02136
100 Highland Ave, Milton, MA 02186
DIRECTIONS

All materials © Hyde Park Pediatrics
2003-2008
Contact Us

 
Home PCHI Harvard Medical School Directions Home