Appointment Request 

This form is not intended for urgent appointments or for appointments you may need within 48 hours. If this is an emergency, call 911 or go to your local emergency room.

The data you enter on this form will be securely transmitted to Geisinger using SSL 128-bit encryption.

Notice of Privacy Practices

Geisinger values your trust. We will strive to continue to maintain the privacy of your protected health information. We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to your protected health information. We are also required to abide by the terms of our Notice.

To read the Notice in its entirety, please visit Notice of Privacy Practices

If you have any questions about this Notice of Privacy Practices, you may ask a member of the staff where you receive health care services. You may also contact our Privacy Officer at (570) 271-7360.

Appointment is for:
Enter as mm/dd/yyyy
If you are already a Geisinger patient.
This number is used for identification purposes only.
Requested by:
Enter as 570-271-0000
Best Time to Contact You by Phone:
 
If different from Requestor
NOTE: If you have managed care(HMO)insurance, you will need to contact your primary care physician
 
to acquire prior authorization before requesting a specialist appointment below.
 
Appointment desired:
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Visit Find a Doctor for our Doctor & Specialist Directory
Were you referred by a Physician?
If yes, type the referring Physician's name and phone number in the boxes below.
 
Preferred time of day for the appointment
 
We will make every effort to schedule your appointment as close to the time you select.
 
Preferred day of the week for the appointment