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Appointment Request

Appointment Request
* 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?*
 
 
 
 
Preferred Time of Day for Your Appointment*
1st choice   2nd choice
select
select
 
select
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
select
 
 
Briefly Describe Your Symptoms or Reason for Doctor Visit
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