Appointment Request

For an emergency, call 911.

This form may be used to request a routine (i.e. non-urgent) appointment at Cooper Clinic.

You will be contacted BY PHONE, usually the same day we receive your email, to schedule your appointment.
(Note: Our call may not appear as "Cooper Clinic" on Caller I.D.)

If your medical need is urgent (but non-emergency), call your physician’s office directly or visit one of our three ProMed Urgent Care Clinics. ProMed locations are open 7-days-a week and treat patients without appointments.

Please Note:
Online appointment request are only monitored Monday – Friday, 8:00am – 5:00pm.
All request made outside of these hours will be processed the next business day.

Please begin by Selecting a Physician OR a Department
(Complete sections 1 or 2 below)

Do you wish to see a specific physician?:

If you do not have a physician preference
please proceed to step 2.

Select a Physician:

The physician you selected above practices in the following department:

If you did not select a specific physician above
please select the appropriate department:

Please complete all fields before submitting request:

Patient Name:
Parent or Guardian (if patient is a minor):
Patient's Date of Birth:	/ /
Preferred time of day to be called:
Phone number where you can be reached during your preferred time:	- or: - Note: Our call may not appear as "Cooper Clinic" on Caller I.D.
Your Email Address:

Appointment Request

Please begin by Selecting a Physician OR a Department (Complete sections 1 or 2 below)

Please begin by Selecting a Physician OR a Department
(Complete sections 1 or 2 below)