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Appointment Request
Fairway Children's Medical Group,2707 E Valley Blvd, Ste 215, West Covina California
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Appointment Request
909-594-3382
Appointment Request
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Are you a new or returning patient?*
New
Returning
Child’s First Name*
Child’s Last Name*
Date of Birth*
Sex*
Male
Female
Other
Reason
Well Checkup
Sports Pre-participation Exam
Sick Visit
Need Referral
Appointment Change needed
Other questions
Lab result question
Primary Caregiver Name*
Primary Caregiver Phone*
Primary Caregiver Email*
Secondary Caregiver Name
Secondary Caregiver Phone
Email*
Phone*
Preferred Language
English
Mandarin
Cantonese
Spanish
I have read and agreed to the
Privacy Policy
and
Terms of Use
and I am at least 13 and have the authority to make this appointment.
I agree to receive text messages from this practice and understand that message frequency and data rates may apply..
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Appointment Request
Are you a new or returning patient?*
New
Returning
Child’s First Name*
Child’s Last Name*
Date of Birth*
Sex*
Male
Female
Other
Reason
Well Checkup
Sports Pre-participation Exam
Sick Visit
Need Referral
Appointment Change needed
Other questions
Lab result question
Primary Caregiver Name*
Primary Caregiver Phone*
Primary Caregiver Email*
Secondary Caregiver Name
Secondary Caregiver Phone
Email*
Phone*
Preferred Language
English
Mandarin
Cantonese
Spanish
I have read and agreed to the
Privacy Policy
and
Terms of Use
and I am at least 13 and have the authority to make this appointment.
I agree to receive text messages from this practice and understand that message frequency and data rates may apply..
Submit
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Appointment Request
