Kearney Clinic, P.C.

*First Name:

Middle Initial:

*Last Name:

*Zip Code:

*Home Phone:

Our goal is to make your visit to Kearney Clinic as convenient and enjoyable as possible. To request an appointment, please complete the form below. Please be sure to provide your phone number (with area code) so that we can call you to confirm your appointment. You may also call (308) 865-2141 and ask to make an appointment.

Kearney Clinic is open Monday through Friday from
8:30 a.m. to 12 p.m. and 1:30 p.m. to 5:00 p.m. and Saturday from 8:30 a.m. to 12 noon.

NOTE:

		Appointment requests must be submitted at least 24 hours in advance.

		Medication requests cannot be submitted on this form.

		To cancel your appointment you must call 308-698-1576.

		You will receive a call back to confirm your appointment request.

		Medication refill requests or Lab orders cannot be requested on this form.

Please complete the form in its entirety. You must complete all the required fields noted in *red. Incomplete submittals may delay processing.

PATIENT'S NAME

PATIENT'S HOME ADDRESS

	Check this box if the patient's name is someone other than yourself.
	Your name, if different from patient's name:

INFORMATION FOR PHYSICIAN'S OFFICE
The following information is required in order to request an appointment:

Gender:

Patient ID # (if known)

PHYSICIAN APPOINTMENT REQUEST INFORMATION

Request appointment with:

REASON FOR APPOINTMENT

In order for us to schedule your appointment, please provide a short description of the reason for your visit.

Request an appointment within:

APPOINTMENT TIME PREFERENCES

We will make every effort to accommodate your preference for an appointment. Appointment availability is also contingent on physician availability.

	Mon	Tue	Wed	Thu	Fri	Sat
Morning
Afternoon						n/a

CONTACT INFORMATION

*Contact Phone: Alternate phone number if unavailable at home phone number.

Area Code - - Ext.

Best time to call you to confirm an appointment:

Please Note: This form is not on a secure server and the information could be viewed by an outside source. By submitting information, you certify that you are at least 18 years old.




	Online Bill Pay

	Appointments

	New Patient Pre-Registration

	Consent Form

	Notice of Privacy

	Fees and Payment

	Insurance

	Satisfaction Survey

	Web Nursery


	Return to Home Page