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 *
---32837 Hunter's Creek34741 Kissimmee "The Loop"32819 Dr. Phillips
Select the location most convenient to your needs.

Requested Pediatrician *
---Any AvailableDr. N MerchantDr. C Chan-RagazzoDr. H AbouelmagdDr. T BlocksonDr. R Patel
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.