Oak Lawn Immediate Care

Appointment

Online Appointment

Patient Information

First Name*:

Middle Name:

Last Name*:

Gender:

Contact Information

Contact Name (if different than patient name):

Address*:

City*:

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:

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 Oak Lawn Immediate Care at (708) 576-4700 .

If you feel that you may have a life-threatening condition that requires emergency care, call "911" or go to the nearest hospital-based emergency room.