Appointment

Online Appointment

Patient Information










Contact Information






State*:

Zip Code*:

Telephone*:

Email Address:


Insurance Information

Primary Health Insurance

Name:

(Please specify Other)
Primary Health Insurance

Type:

Policy # :

Group # :

Primary Holder First Name:

Primary Holder Middle Name:

Primary Holder Last Name:

Primary Holder Name:

Insurance Claim Phone #:

Secondary Health Insurance

Type (if any):

Policy # :

Group # :

Insurance Claim Phone #:


Appointment Information

Primary Care Provider or Referring Physician’s Name:

Primary Care Provider or Referring Physician’s Phone Number:

Have you ever had an appointment at Kendall Immediate Care?


Do you have a particular physician that you would like to see?


If yes, please enter that physician’s name here:

Have you seen this physician before?


Type of service requested:

Reason for appointment:


Time Preference
Day of week:

or

Time of day:

Additional comments:


Your appointment will be made by the time you come into the office. For additional questions about your appointment, please call the DupageMedicalPlaza at 630 – 953 – 4500.