Online Appointment

For your convenience, we are pleased to offer Online Appointment Requests. Complete the following form, and we will contact you within two business days to confirm your appointment.

Online Appointment Requests are intended for established patients regarding non-urgent visits. If you require assistance in scheduling a same-day sick visit, please call our office directly:

Burlington Pediatrics: 336.228.8316
Burlington Pediatrics West: 336.524.0304
Mebane Pediatrics: 919.563.0202

Please be advised that the following request is not SSL encrypted for information security. As always, if you are experiencing a life-threatening emergency, call 911 and seek prompt medical attention.

Patient Name: required

Date of Birth: required

Person Requesting the Appointment: required

Relation to the Patient:

Telephone Number: required

Alternate Number:

Email Address: required

Preferred Method of Contact:

Email
Telephone

Appointment date and time: required: choose at least one date or check First Available

First Available

Specific Dates:

1st Preference:

2nd Preference:

Office Location:

Burlington Pediatrics: 530 West Webb Avenue
Burlington Pediatrics West: 3804 South Church Street
Mebane Pediatrics: 943 South Fifth Street

Provider Preference:

@ Burlington Pediatrics

@ Burlington Pediatrics West

@ Mebane Pediatrics

Reason for Visit:

Comments:

Your appointment request is incomplete; please make sure all required fields are filled out correctly.