Appointment Request

Making an appointment is easy with our online Appointment Request Form. Fill out the form, submit, and one of our schedulers will respond back promptly with a confirmed appointment time for your child.


All requests submitted online using our appointment request form will receive a response within 1-3 business days, Monday to Friday 9:00 am to 5:00 pm, except on weekends and holidays. Requests submitted on weekends and holidays may take longer please allow ample time or email us directly:
The Appointment Request Form is for existing patients only. For New Patients, please call our office directly to schedule an appointment.


Patient Name *

Date of Birth *

We accept newborns to 18 yrs old.

Phone Number*

Preferred format: (123) 456-7890

Parent / Guardian Name *

Relationship to patient *

What is your relationship to the patient for whom you are requesting an appointment for?

Email *

Merchant Pediatrics will be responding to this email, please use a password protected account to ensure your privacy.

Location *

Select the location most convenient to your needs.

Requested Pediatrician *

Please select the pediatrician that is listed on your child(ren) insurance card(s)or call the insurance company to find out who is the PCP assigned. Thank you.

Reason for Appointment *

This form is intended for well visits, immunizations and non-sick visits.

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