Request an Appointment

To schedule an appointment to see a physician or receive outpatient rehabilitation at Good Shepherd, please complete and submit the following form. A Good Shepherd representative will contact you within two business days to schedule an appointment. This is a secure form and the information you provide will enable us to assist you as efficiently as possible.

If you have a general question or need assistance, submit a Contact Us form [1].
If you represent a physician and would like to refer a patient, submit a Refer a Patient form [2].

* Required fields

Personal Info

Name: *

Address: *

City: *

State: *

Zip Code: *

Phone Number: *

E-Mail: *

Date of Birth: *

Gender: *

Male

Female

Insurance company: *

Medical Info

Describe condition/illness: *

What type of appointment are you requesting?:

Physician consult

Therapy

At which Good Shepherd site would you like to make an appointment?:

View our location map [3]

Do you have a prescription for therapy?:

Yes

Who referred you to Good Shepherd?:

Physician

Self-referred

If a physician referred you, please provide his/her name:

For what time and day of the week would you like to schedule an appointment?:

Other comments:

Would you like to receive occasional e-mail updates on new programs and services, special events and more from Good Shepherd?:

Yes

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Good Shepherd Plaza • 850 South Fifth Street • Allentown, PA 18103
610-776-3100 • Info: 1-888-44-REHAB • Contact Us

Source URL: http://goodshepherdrehab.org/request-appointment

Links:
[1] http://goodshepherdrehab.org/contact-us
[2] http://goodshepherdrehab.org/refer-a-patient
[3] http://goodshepherdrehab.org/files/location-map/location-map.html