This form is not intended for same or next day appointments. Please call 312.567.2600 for assistance with same or next day appointments, or visit one of Mercy Hospital's Immediate Care facilities.

We are happy to assist you in scheduling your visit! To begin, simply complete the form below and you will be contacted by the next business day. Every effort will be made to accomodate your requested timeframes; however, please note that in some instances we are limited in the time frame in which we can schedule your visit based on the physician's office or outpatient area's schedules. If you have quesitions or prefer to schedule a visit by phone, please call Mercy Hospital's Central Scheduling Department at 312.567.2273.

Thank you for choosing Mercy Hospital!



Patient Information

Patient Name:

Home Address(Street, City, State, Zip):

Date of Birth:

Gender:
Male: Female:

Provider:

Insurance Carrier:

Please note: Patients are encouraged to check with their insurance carrier to verify this physician is a participating provider. If this physician is a specialty care provider, please contact your insurance carrier to find out if pre-authorization or a referral from your primary care provider is required to access care. Some specialty providers require pre-authorization or referrals from primary care providers; please contact your insurance carrier to find out if your plan requires this. Patients requesting outpatient testing apointments are encouraged to check with their insurance carrier to verify if the test is covered and/or requires pre-authorization.

Where To Contact You

Name:(if different from Patient Name)

Daytime Phone:

Best Time to Contact You:



Appointment Information

For Physician Appointments

Name of physician you wish to see:

If you would like assistance choosing a physician:
Primary Care
Pediatrics
Specialist
Specialties:


For Outpatient Testing Appointments

Name of test you wish to schedule:

Requesting Physician:

Preferred Appt. Day/Time

We will do our best to accommodate your request, however scheduling is conditional on appointment availability.

First Choice:
Day: Time:

Second Choice:
Day: Time:

Please tell us why you are seeking an appointment with a physician, or why your physician has requested this test:

Optional Information

This information is used for Marketing purposes only. This information is NEVER shared with third parties.

How did you hear about Mercy Hospital?

Have received inpatient or outpatient services at Mercy Hospital in the past?

If you have questions, concerns or changes to a recently submitted appointment or referral request, you may speak with a Physician Referral staff member by calling the Mercy Hospital Referral and Customer Service line at 312.567.2600, Monday through Friday, 8:00am - 4:30pm.