The Children's Clinic | Request An Appointment

To request an appoinment for PEDIATRIC MEDICAL CARE,
please complete the following form we will contact you as quickly as possible.

Pediatric Primary Care
238 Aresenal St. - Watertown - (315) 782-6400

Reason for Appointment
I would like to...	New Patient Schedule a Physical Change an appointment
If you are changing an appointment, what was your scheduled appointment time/date?

Patient Information
Patient's First Name
Patients Last Name
Patient's Date of Birth
Reason for the Visit:
Insurance Provider
Insurance Expiration

Contact Information
Your Name?
Preferred appointment day of the week?
Preferred Appointment Time?
How can we reach you best by phone?	( ) -
Best time to call?	Morning Afternoon Evening
OK to leave a message?	Yes No
Email Address
Additional Comments

Please note that when requesting an appointment, this form does not guarantee an appointment time.

A member of our staff will contact you by phone for
appointment conformation.

If you require immediate or further assistance please contact us directly by calling:

(315)782.6400



	238 Arsenal St. Watertown, NY 13601 P. (315)782-9450 F. (315)782-2643


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