top of page

SPORTS  PHYSICAL  APPOINTMENT  REQUEST

Registration

Child's Birthday
Month
Day
Year
Requested Appointment Date and time
Month
Day
Year
Time
HoursMinutes
Child's Primary Insurance

If we cannot accomodate your appointment request, we will call you. Otherwise, please arrive 15 minutes prior to your appointment.


If your child needs their annual Well-Child Check (WCC) visit, we will include the Sports Physical in that visit, which is usually covered at 100% by most insurances (please verify eligibility for the WCC). If the child is not eligible for their annual WCC, the cost for the Sports Physical is $35.

Please do not include any medical information or health concerns in this form. This form is used only to request an appointment and is not a secure method of communicating protected health information.


Children under 15 will need a parent or legal guardian to come with them to their appointment.

We encourage a parent/guardian to attend even if the child is 15 or older.

No one will be denied access to services if they are unable to pay. There is a discounted/sliding fee schedule available based solely on family size and income.

bottom of page