Check-in to Emergency Department West Bentonville

Projected Treatment Time

Friday, March 28 at 8:30 pm

Reason for visit * ( Max length 250 )

Referring Physician

Has the patient visited Emergency Department West Bentonville before? *

Does the patient have a primary care doctor? *

Email Address *

We need your email address to send you the details of your visit. This email also includes cancellation instructions. No spam, we promise.

Patient's First Name * (Legal Name)

Middle Initial

Patient's Last Name *

Date of Birth *

Phone Number *

Gender *

Zip Code*

Contact Name (if different from patient)

Terms and Conditions

I have read and agree to the InQuicker Online Scheduling terms of use. *
I have read the when to call 911 guide and understand that Online Scheduling is not to be used for life-threatening, debilitating, or emergent medical conditions. I have determined my condition is not life-threatening and I can wait until I arrive for evaluation and treatment. *
I agree that the facility or provider with whom I am making an appointment and/or its affiliates may contact me regarding health-related education, information, services, or advertising - our terms and conditions.