Appointment Request

1. Appointment
2. Patient
3. Contact
4. Insurance

* Required Fields

This form is for non-emergency situations only. It will be submitted to Mercy On Call, not to a physician office. If you have an immediate health concern please call Mercy On Call at 319-358-2767 or 1-800-358-2767.

Want to make an appointment for a mammogram screening? Please use our Mammogram Appointment Request Form.

Doctor You Want to See

Select a Specialty

select

- OR -

select

Do You Currently Have a Primary Care Doctor?*

YesNo

Preferred Time of Day for Your Appointment*

1st choice

2nd choice

select

(We'll make every effort to give you an appointment close to the time you select.)

Preferred Day of the Week

1st choice

2nd choice

select

Briefly Describe Your Symptoms or Reason for Doctor Visit

Online Services

Appointment Request