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Request an Appointment

* Required Information



Click Here if you allredy have a Meriter MyChart account

If you currently have a Meriter MyChart account, please click here to request an appointment.

Please fill out the form below

If you don’t have a Meriter MyChart account and would like to request an appointment with a Meriter physician, please complete the form below.

Notice:
This form is not for urgent health problems, same-day appointment, or appointment cancellations. Please allow 1 business day for a Meriter representative to contact you. For same-day appointments please call the clinic directly, and for medical emergencies please call 911.

Select a Preferred Doctor or Clinic:

Current Doctor:



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Please select a doctor from the right
Select by Clinic:
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Select by Specialty:
Select Specialty Select Doctor

Appointment Preference:



PATIENT INFORMATION
First Name: * Last Name: *
Date Of Birth:* Phone Number:*
Email Address: Alternate Phone:
Address Information: *
Address 1:
City:
State: Zip:



Insurance:

Reason For Appointment:*