Request Well Visit Check-up

Request Well Visit Checkup

Please use this form to submit requests for WELL VISITS ONLY.

Please allow 3 days for us to schedule your well visit, if this request is sent on the weekend.

DO NOT USE THIS FORM FOR SICK APPOINTMENTS!
FOR SICK APPOINTMENTS, PLEASE CALL 919-938-3749 OR 919-779-4800.

Parent or Guardian's Name*
First Last
Child's Name*
First Last
Child's Date of Birth*
Date Format: MM slash DD slash YYYY
Phone*
Email*
Message