Request an Appointment

To expedite your appointment request, you will need information from your health insurance card. Or:
Use MyChart Call 800-777-8442 (toll-free)

Contact Information

This appointment is being made for…

Myself

Someone Else

Contact Name

Relationship to Patient

Email *

Phone *

When can we call you?

May we leave a message?

Patient Information

First Name *

Middle Name

Last Name *

Maiden/Former Name

if applicable

Street Address *

Zip *

City

State

Date of Birth *

Was patient born or previously seen at UI Hospitals and Clinics?

Insurance Information

Does the patient have insurance?

Yes

Insurance Company Name *

Policy or Member Number *

Policy Holder's Name *

Policy Holder's Date of Birth *

mm/dd/yyyy

Insurance customer service phone number

About Your Appointment

Preferred Physician or Specialty

What is the purpose for your request? *

Please leave blank

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