Outpatient First Appointment Request Form

To schedule your first outpatient appointment, call 866.852.4001 or use the appointment request form below.

If you have questions about outpatient services at Pine Rest, please call our Central Access at 866.852.4001. We are available 8 a.m. to 6 p.m. Eastern Time (ET), Monday – Friday except for major holidays.

For after-hours emergencies, please call the Pine Rest Contact Center which is staffed 24/7 at 616.455.9200 or 800.678.5500.

Outpatient Initial Appointment Request Form

  • Please fill out the information below and staff from our scheduling department will contact you within 48 business hours to set up an initial appointment.
  • Patient Information

  • Legal Name of Patient * Required
  • Parent/Guardian Name (if applicable)

  • Name of Contact Person * Required
  • Services Requested

    Please indicate the type of services for which you would like an appointment (check one or more boxes below). Scheduling staff will be able to answer questions to help you determine which appointment type is best for you.
  • I would like to set up an appointment for: * Required
  • Gender, age, etc.
  • Insurance Information

    Please provide your insurance information so that we may partner you with a provider who participates with your insurance.
  • Insurance Subscriber Name * Required
  • Contact Information

    The scheduling department is available to call between 8:00 AM and 5:00 PM Monday through Friday. Please provide your name, phone number and convenient times for our staff to contact you.
  • I prefer to be contacted on the following day(s):
  • I prefer to be contacted during the following time(s)

  • Thank you for your interest in scheduling outpatient services with us. Staff will contact you based on the contact information that you have provided above. If you are in need of immediate medical attention, please call our Contact Center which is staffed 24/7 at (800) 678-5500.

If you have any questions, please call 866.852.4001.