SCH Outpatient - Scheduling Request

Scheduling Request for Outpatient Testing or Diagnostic Services

St. Clair is happy to assist you and to ensure clinical services are scheduled correctly based on your provider order. Due to the complexity of scheduling your service, St. Clair is asking for basic information related to your scheduling needs and will phone you at your convenience, based on the information below, to complete and confirm your scheduled visit.

Please complete the following information and then click the “Submit Request” button to complete your request. You will be contacted within 1 business day of submission.

Scheduling Request

Requestor Information

Patient Information

When Can We Contact You?

Requested Service

This request is for:

Myself Another

Title

Your Legal First Name*

Please provide a first name.

Your Legal Last Name*

Please provide a last name.

What is your relationship to the patient?

Please provide a relationship.

Title

Your Legal First Name

Please provide a first name.

Your Legal Last Name

Please provide a last name.

What is Your Birth Date?

Please provide a birth date.

Address

Address Line 2

City

State

Zipcode

Best Day Time Phone Number to Reach You:

Please provide a phone number.

Secondary Phone Number (if available):

Preferred Return Call Time

All return calls placed between 8:30 AM – 4:30 PM. Please select a return call time.

Please provide a return call time.

Type of Visit (Specific Service / Test)

Please provide a type of visit.

Ordering Provider Name:

Please provide an ordering provider.

Type of Visit (Specific Service / Test)

Please provide a type of visit.

Ordering Provider Name:

Please provide an ordering provider.

Type of Visit (Specific Service / Test)

Please provide a type of visit.

Ordering Provider Name:

Please provide an ordering provider.

Do you have a prescription / order for services?

Yes No

Additional Comments / Notes:

Your scheduling request has been submitted.

You will be contacted within 1 business day of submission by a scheduling representative to confirm your request for service.

Please have your insurance information and the providers prescription/order for the requested service so we can confirm the visit.