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.

To talk to a scheduler, call our Physician Referral Line at 412-692-PEDS (7337) from 7 a.m. to 7 p.m. Monday through Friday.

* Indicates a required field.


Patient Information
First Name *
Middle Initial
Last Name *
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Patient's Date of Birth * Calendar
Gender * Male Female
Health Insurance *
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 *
Best Time to Call
Appointment Information
Specialty *
Preference  
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 Calendar
How did you hear about us?  
Additional Information
(Were you referred by another physician? If so, please provide his/her name.)  
* This extra step helps prevent automated abuse of this application    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.


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