Referring Provider Online Appointment Request

NOTICE: THIS FORM IS TEMPORARILY UNAVAILABLE

 

Please enter your contact information on this form.
Entries marked with * are required.

Patient Information

First Name*
Middle Name
Last Name*
Date of Birth* 
Phone*
Best Time to Reach Patient
Email
Insurance

Referring Provider Information

Internal (UIC) Provider
First Name*
Middle Name
Last Name*
NPI #*
Email*
Office Name
Office Address*
City* 
State*
Zip*
Office Phone 
Fax
Office Contact Name
Office Contact Phone
Office Contact Email

Appointment Information

Clinic
Location Illinois Eye and Ear Infirmary
Millennium Park Eye Center
Physician Name (if blank we will use first available)
Diagnosis*
Comments

Appointment Confirmation

After the appointment is made, we will notify the Office Contact of the appointment time and date.