Request an Appointment at Legend

APPOINTMENT REQUEST FOR LEGEND INTERNAL MEDICINE & URGENT CARE

Welcome to Legend Internal Medicine, Urgent Care and Diagnostic's online appointment scheduling. We will make every effort to accommodate your request. Please note, however, only routine appointments should be requested online.

If you have an immediate need or concern, contact our office directly, (817) 923-8484.

If this is an emergency, please call 911.

Required items are marked with a red asterisk *

REQUEST APPOINTMENT

Patient's Last Name *:

Patient's First Name * :

Patient's Middle Name or Initials :

Sex :

Date of Birth :

Daytime Phone Number :

Evening Phone Number :

Cell Phone Number * :

Insurance Type :

Are you a new Patient? :

yes
No

Who is your Provider :

Are you willing to see another physicianin order to get the date or time requested? * :

yes
No

Which is important to you? :

Seeing my Physician
Date and time preference

Purpose of Visit * :

Describe symptoms (Illness only) :

Person Making Appointment :

Relationship to Patient :

Return E-mail Address * :

Schedule Preference

Select the days which you are available and we will attempt to match your request with your physician's schedule.

The office may not be open on all days listed. The earliest date that an appointment might be available is 3 working days from today's date, depending on the physician's schedule. Please do not select Saturdays or Sundays. This will allow us enough time to confirm your appointment request.

Hours of Operation:

Monday to Friday 7:00am to 5:00pm

Preference	Date	Time
1st: *
2nd:
3rd:
4th:

Additional Comments: