St. Francis Hospital

Patient Services

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Online Appointment Request

Thank you for choosing St. Francis Hospital for your outpatient appointment.

Please understand that we will do our best to meet your scheduling needs, but due to the high volume of appointment requests, selected preferred times are intended to serve only as guidelines. Please note that this is an appointment request and a scheduler will call you shortly to confirm your appointment.

 

* Asterisk indicates a required field.
 

 Patient Information 
 Please enter full legal name below
     
First Name*
 MI
 Last Name*
Date of Birth* (MM/DD/YYYY)
 Gender
Female Male
Mailing Address
Street Address
 Apartment
City
 State
 Zip Code
Daytime Phone Number*
 Alternate Phone Number
Email Address*
Retype Email Address*
 

 Medical Information
     
Type of Insurance*
    
Pre-certification Number (If required)
    
Are you a new patient?* No Yes
Do you have a physician's prescription (note) for this test/procedure?* No Yes
 
Name of Ordering Physician
Reason for Procedure
(illness, accident, routine, followup)*
Procedure*
 
Other Procedure (Please indicate)
 

 Additional Comments / Special Requests
 
 

 Scheduling
 
Preferred time of day for appointment - (check all that apply)
Please understand that we will do our best to meet your scheduling needs, but due to the high volume of appointment requests, these preference(s) are intended to serve only as guidelines.
 
Day of the week for appointment
Monday Tuesday Wednesday Thursday Friday
Saturday (if available) Sunday (if available)
 
Time of Appointment:
First choice
Second choice
Requesting an appointment as soon as possible (first available)
 

 

Please note, on the date of your visit you will need to bring the following:

    • Your prescription (or physicians note)

    • Insurance cards

    • Identification

    • Referral (if applicable)

If you have any questions or problems related to this form, or to request an appointment by phone please contact these scheduling departments.
 
Central Scheduling 302-421-4141 (M-F 7:30AM-5:30PM)
Physical Therapy 302-575-8250 (M-W-F 9:00AM-5:00PM, Tu –Th 11:00AM-7:00PM)
Sleep Center 1-866-363-7535 (M-TH 8:30AM-8:00PM, F 8:30AM-7:00PM)