Mercy Medical Center North Iowa

This form will generate an e-mail to Mercy Family Clinic - Forest Park.


Please be aware of the following if you contact us by e-mail:


  • Do NOT use e-mail to seek urgent or emergent medical attention. If you are in need of immediate medical care, please go to the nearest emergency department or call 911.

  • You will not receive an e-mail response from the clinic. Your message will be reviewed and a clinic associate (not a physician) will contact you by phone as soon as possible and no longer than within 1 business day.



* Indicates required information
Patient Name: * 
Contact Name: (if different than above) 
Daytime Telephone Number: * 
Patient date of birth: *  (mm/dd/yyyy)
Email: * 
Check the reason for your request 



Appointment scheduled for 2 days out:  (mm/dd/yyyy)
Brief description of request: 
Acknowledgement * 
Authentication * 

If the challenge words are too difficult to read, click here to refresh.