Please fill out the details in the form below to submit a new appointment request for Fairhaven Pediatrics.

DISCLAIMER: For urgent and same day appointment requests, please call or text (360) 685-1225.

If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment requests only.

Patient Name

First Name

Last Name

Date of Birth

YYYY

Gender

Male

Female

Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Reason for Visit

Other Description

If you selected "Other" please let us know what this visit is about

Preferred Day of the Week

Preferred Time of Day

Insurance Provider