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Request an Appointment

Online Appointment Request

Online Appointment Request

Thank you for choosing St. Mary Medical Center 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 within the next business day to get the information required to confirm your appointment.

If you experience any difficulty in using this form, please email

If you are looking for a physician, please contact the Physician Referral Office by email or call 215-710-5888 or check our Online Physician Directory. To schedule an appointment with a physician, please call the physician's office directly.

* Asterisk indicates a required field.

Patient Information
Please enter full legal name below
First Name*
Last Name*
Date of Birth* (MM/DD/YYYY)
Female Male
Mailing Address
Street Address
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)*
Other Procedure (Please indicate)

Additional Comments / Special Requests

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)
First choice
Please select a “Type of Test” to view available appointment times.
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:

  1. Your prescription (or physicians note)
  2. Insurance cards
  3. Identification
  4. 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 between 8 a.m. and 4:30 p.m.

These scheduling departments handle routine, non-emergent exams. The physician should call the particular department directly if an exam is required on an urgent or emergent basis. The staff in these areas will assist with special needs.

Central Scheduling 215-710-2208
MRI 215-710-2208
Cardio-Pulmonary-Neurology Diagnostics 215-710-2521
Physical Medicine and Rehab 215-710-2223
Sleep/Wake Disorder Center 215-710-6744