Online Appointment

Patient Information

Contact Information


Zip Code*:


Email Address:

Insurance Information

Primary Health Insurance


(Please specify Other)
Primary Health Insurance


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:


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.