Appointment Form Rogers

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Appointment-Form-Rogers

• Pediatric care on your schedule
• Walk-in convenience
• For all simple illness or injury
• Seven days a week
• No appointment needed
• Available at all locations

Locations
Click on location for details

Brooklyn Park

Edinburgh Medical and Dental Plaza
8500 Edinbrook Parkway
Brooklyn Park, MN 55443
Phone 763•425•1211
Fax 763•425•6277
Visit Brooklyn Park home page

Calhoun

3910 Excelsior Boulevard
St. Louis Park MN 55416
Phone: 952-562-8787
Fax: 952-562-8788
Hours: 8 am to 5 pm
Monday through Friday
Visit Calhoun home page

Maple Grove

Bass Lake Center
12720 Bass Lake Road
Maple Grove, MN 55369
Phone 763•559•2861
Fax 763•559•1338
Visit Maple Grove home page

Plymouth

West Health Campus
2855 Campus Drive Suite 350
Plymouth, MN 55441
Phone 763•520•1200
Fax 763•520•1201
Visit Plymouth home page

Rogers

13980 Northdale Boulevard
Rogers, MN 55374
Phone 763•428•1920
Fax 763•428•3162
Visit Rogers home page

PIP Hours
By Appointment 
Monday through Friday 
at all offices 8:00 am to 5:00 pm

ReadyCare Hours
Walk-ins Welcome
Monday through Friday at all offices 
8:00 am to 5:00 pm

Monday through Thursday Evenings 
Maple Grove 5:00 pm to 8:00 pm

Saturday and Sunday 
Maple Grove 8:30 am to 12:30 pm

If you are a new patient to Partners in Pediatrics, please call to make an appointment; do not submit this request by email.

Please complete one form for each child and each appointment. A member of our scheduling staff will contact you within two business days (Monday through Friday) with an appointment day and time.

Child's Name *

Child's Date of Birth *

Parent's Name *

Address *

City/State/Zip *

Daytime phone number *

Alternate phone number

Insurance *

E-mail (Please list e-mail address) *

Please contact me by *

Email (above)

Main phone number (above)

Alternate phone number (above)

Other phone or email:

Please complete ONE of these four types of appointments:

Well child visit; please list child's age

Recheck of existing condition; please specify

Other; please specify

Illness; please specify

Does your child have additional health issues *

Yes, please list

Appointment needed within *

Within 7 days

Within 30 days

Within 60 days

Please schedule this appointment with *

If provider is not available, may we schedule with a different provider? *

Yes

If yes, please select: *

Any provider

Male provider

Female provider

Please fill in one of the three (3) boxes below

Box 1

These are the days available

These are the times available

Box 2

Best days for this appointment, check all that apply:

Best time:

Box 3

These are the days and times we are not available for this appointment:

*) Required fields

Click here for PIP's well child exam schedule and forms you
can print out and complete before your appointment.

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