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FORMS: To expedite the return of your form, please complete the sections pertaining to your child, then email the form directly to [email protected] OR use the UPLOAD FILE button below the Patient Information boxes below. NOTE: To send multiple pages use a scanner APP found on the APP store or Google Play. Scan your documents with your device, then upload the one file here.

We will complete the form[s] and return to you via secure email. If emailing the form, including your cell phone number in case we have questions.

NON-URGENT QUESTION OR REQUEST: If you have a non-urgent question or a request that is general in nature please use the form below. Expect a response within 1 business day (Monday - Friday).

If you have a question that requires speaking with a nurse to discuss your child's medical condition, please call Monday-Friday between the hours of 7:30-1:00 pm.

If you are calling after 1:00 pm Mon-Fri and your child is ill, we can schedule an appointment to address your child's healthcare needs. The appointment line is 317-621-9000. We also offer walk-in clinics on the weekends for ill children.

WALK-IN CLINICS
Sat: Castleton location from 8:30-10:00am
Sun: 146th location from 4:30pm-6:00pm

Patient Information

Contact Information

Parent / Guardian Name

Give first and last names

Primary Phone

Use the format 317-555-1212

Patient Name

Give first and last names

Alternate Phone

Use the format 317-555-1212

Date of Birth

Use the format MM/DD/YYYY

Email

Primary Care Physician

Upload File

Submit question or request

I understand that this request form is NOT for urgent medical situations and is NOT a substitute for my child being examined by a medical provider. This request will be addressed within one business day.

Northpoint Pediatrics

Form Upload and/or Ask a Question

Locations

Community Health Pavilion on 146th

Community Hospital North Campus