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Need a doctor appointment but don't have the time to call and coordinate your schedule? HealthConnection is here for you.

Please use our Online Physician Directory to locate the doctor you would like to see, and HealthConnection will do the rest. Your personal information will be held in strict confidence. In addition to finding an appointment day and time that meets your needs, we also will ensure that the physician you see accepts your medical insurance and meets your personal preferences.

To request an appointment with a physician on staff at Northwest Community Hospital, please complete this form. All fields are required.

You will receive a confirmation phone call from HealthConnection. For further information, call HealthConnection at 847.618.4YOU Monday through Friday, 8:30 am to 4:30 pm.

Title
Mr. Mrs. Ms.
Patient First Name Patient Last Name
Birthdate  
(mm/dd/yyyy)
Address
City State Zip Code
Phone
Email Address
My Appointment Preferences:
Physician First Name Physician Last Name
Physician Specialty
Are You A New Patient?
Yes. No
My Primary Health Insurance
General Reason for Appointment
Preferred Appointment Day Preferred Appointment Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Early Morning
Late Morning
Early Afternoon
Late Afternoon
Evening
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Last Updated 05/12/2009