Appointment


Lombard Immediate care offers a convenient option for non-life threatening illness and injuries, such as sore throats, bruises, cuts, broken bones and high fevers.

Planning on coming today? Don’t worry about getting in line – Check in Online Now.
Don’t want to use Online Check-In? Remember, you can always just walk in!

Patient Information

First Name*:
Last Name*:
Gender*:
 Male Female

Contact Information

Contact Name(If Different Than Patient Name):
Address:
City*:
State*:
Zip Code*:
Telephone*:
Email Address*:

Insurance Information

Primary Health Insurance Name*:


(Please specify Other)
Type of service requested*:
Reason For Appointment*:

Time Preference

Appointment Date(YYYY-MM-DD):
Time Of Day*:
Additional Comments: