Appointment Request Form

Appointment Request Form

If this is a medical or mental health emergency, call 911 or go to the nearest emergency room.
Lehigh Valley Health Network, part of Jefferson Health, is firmly committed to our valued partnerships and recognizes the priority care that our active population requires for continued success at any level of competition or lifestyle. Please complete the below form to request an expedited appointment with our highly qualified physicians.

Our care continuum team will also help facilitate priority access into hard-to-reach areas such as advance imaging, rehabilitation services, and more to maximize a successful return to desired activities.
Athlete/Patient Name*

First NameLast Name
Parent Name (if applicable)

First NameLast Name
Patient Class*
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Okay to contact through MyLVHN?

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current School District / Club Program*
Sport (if applicable)
Nature of Current Injury (Body Part, Onset, Previous Studies/Surgery)*
Preferred Clinician (if applicable)
Should be Empty: