Appointment Request

If this is a medical emergency, please call 911 immediately.

Please complete the form below to request an appointment for your child.

We will attempt to contact you within 24 hours or sooner when your request is submitted Monday through Friday during our business hours of 8 a.m. to 4:30 p.m. For requests submitted Friday evening through Sunday or holidays, we will contact you the next business day.

For Forensic Investigations please call, (412) 692-8747

* Indicates a required field.

Patient Information First Name * Middle Initial Last Name * Address Line 1 * Address Line 2 City * State * -- Select -- --> AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY Zip Code * Patient's Date of Birth * Gender * Male Female Health Insurance * -- Select -- Self-Pay UPMC Health Plan HMO/POS UPMC Health Plan PPO UPMC for Life (Medicare) UPMC for You (Medicaid) ASC-Flora Health Network Blue Chip Cigna Healthcare Cigna Healthcare PPO Devon Health Services, Inc Family Care Network Gateway Health Plan Health America Advantra Medicare HMO Health Plan of Upper Ohio Valley Highmark Blue CHIP Highmark Blue Choice Highmark Blue Cross Blue Shield Highmark Complete Care Highmark PPO Blue Preferred Provider Highmark Premier Blue Highmark Select Blue Medical Assistance Maryland Medical Assistance New Jersey Medical Assistance New York Medical Assistance of OH Medical Assistance of PA (Access) Medical Assistance of WV Medical Assistance Other Medical Assistance PA Family Care Network Medicare MedPlus CHIP Railroad Medicare Unison (MedPlus) United Healthcare Other Contact Information Parent/Guardian Name   First Name   M.I.   Last Name     E-mail * Phone Number (where you can be reached from 8a.m. to 4:30p.m.) Format: 555-555-5555 * Preferred Method of Contact * Telephone Best Time to Call A.M. P.M. Appointment Information Specialty * -- Select -- Rheumatology ENT Neurology Medical Genetics Heart Center Infectious Disease Diagnostic Referral (Must provide the Physician's name you were referred by) Nephrology Surgical Services Gastroenterology Hematology/Oncology Child Advocacy Test (Do not Use) Rehabilitation Services Neuro Psychology - (Ages 0-18) allow 6-12 weeks for appointment Child Development Unit - (Ages 0-7) allow 7-8 weeks for appointment Urology Cystic Fibrosis Pulmonology Allergy & Immunity Dermatology Cardiology Preference   No Preference First Available Reason for Appointment (Indicate if you are a new or returning patient and/or enter your desired physician) (Maximum characters: 500) Additional Information to Expedite your Request Preferred Appointment Day/Time AM PM How did you hear about us?   Browsing this web site From another web site Additional Information (Were you referred by another physician? If so, please provide his/her name.)   *    Enter the text exactly as you see it We will attempt to contact you within 24 hours or sooner for requests submitted during the weekday. For requests submitted Friday evening through Sunday or holidays we will contact you the next business day.