To request a well child visit in advance, please complete ALL FIELDS of the secure form below. Someone will contact you within 24 business hours to finalize and confirm an appointment. If this request is received on a Friday or a holiday, your request may be processed the following business day. Should you need further assistance, please contact us by phone. Read terms and conditions below. Patient Information (Fields are below – and all are required fields) Type of Appointment Does your child have any chronic medical problems? (i.e. asthma, diabetes, seizures, ADHD, developmental or school problems)
If so, list below
What day(s) work(s) better for you? (You may choose more than 1)

Monday  Tuesday   Wednesday  Thursday   Friday

Which time slot is better for you?

8:30 A.M. – 10:00 A.M  1:30 P.M.- 3:00 P.M

10:00 A.M. – 12:00 P.M  3:00 P.M. – 5:00 P.M

Person Requesting the Appointment Per our privacy policy, please note that the person requesting the appointment must be the legal guardian or has been listed in our system as an individual that is allowed to request/receive medical information about the child.

Full Name

Contact Numbers

Number 1:	Work    Home    Cell

Number 2:	Work    Home    Cell

Best Time to call? (You may choose more than 1)

8:30 A.M. – 12:00 P.M  5:00 P.M.- 7:00 P.M

12:00 P.M. – 5:00 P.M  NO PREFERENCE

Terms and Conditions Terms and conditions: Submission of this form does not ensure delivery. If staff from Pediatric and Adolescent Center of Grand Prairie & Arlington has not responded to your online request within 24 business hours, please contact the clinic by phone at 972-206-2940. It is also the policy of PACGPA that each physician may see up to 2 children per visit. We must also have a current shot record on file in order for us to confirm any well child appointments. New patients are required to bring their shot record during the initial visit and on every subsequent visit.