Request an Appointment

To expedite your appointment request, you will need information from your health insurance card. Or:
Use MyChart Call 888-573-5437 (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

For Patients and Their Parents

On-line

You'll be asked for basic contact information and the type of appointment you are requesting. We will confirm an appointment time for you within two business days.

By Phone

You will be connected with a representative who will transfer you to the appropriate service for scheduling an appointment.

Using MyChart

Through a patient's MyChart account, patients or their parents can contact their care team to request an appointment. We will confirm an appointment time for you within two business days.

For Providers Referring Patients to Our Care

By Phone

Referrals for emergent conditions should be expedited by phone at 1-800-322-8442.

On-line

Providers will outline the care needs for the individual being transferred.