Kidney Center Clinic
Patient Appointment Request Form

If this appointment request is related to a medical emergency,
please go immediately to an Emergency Department or call 911.
* Indicates a required field, all other entries are optional.
PATIENT INFORMATION
  *First Name Middle Name
*Last Name
Suffix (e.g. Jr, Sr, III.)
*Gender
Male
Female
 *Birth Date
/ / (MM/DD/YYYY)
If you are an existing UVa Patient, please provide one of the following:
Existing UVa Medical Record Number:  
Social Security Number:   - -

PATIENT'S HOME ADDRESS/PHONE
*Line 1
Line 2
*City     *State      *Zip Code 
*Number where you can be reached:
- - Extension
Alternative Number:
- - Extension

INFORMATION FOR PHYSICIAN'S OFFICE
       
*Do you have health insurance?
yes (If yes, the Health Insurance field is required.)
no (If no, proceed to the Appointment Request Section.)
*Health
Insurance
If other, please type in the name of your health insurance plan below:
Policy Number:
Does your insurance plan require that you have a primary care physician (PCP)?
yes no (If no, proceed to the Appointment Request Section.)
If yes, the PCP field below is required.
*PCP Name
Who is your OB/GYN Care Provider?

APPOINTMENT REQUEST INFORMATION
Physician/Healthcare Provider Name

(optional)
*Reason for appointment:
In order for our clerical staff to schedule your appointment please give us a short description of the reason for your visit. If you need to speak directly to a nurse or physician, or need this appointment in less than one week please call your physician’s office, or call our Medical Information and Referral Service (MIRS) at 1-800-251-3627 (toll-free) or locally 434-924- DOCS (3627).
Special Needs
Please let us know if we will need to arrange any of the following for this appointment:
An interpreter for patients with limited English. Requested Language:
A Sign Language interpreter
An escort for patients with low vision or blindness
Valet parking for patients with mobility disorders
A stretcher

Request an Appointment within: One week More than one week
Appointment Time Preferences:
We will make every effort to accommodate your preference for an appointment. Appointment availability is also contingent on physician availability.
 
 Mon 
 Tue 
 Wed 
 Thu 
 Fri 
 Sat 
Morning (8am-noon)
Afternoon (1pm-5pm)
n/a
 

WHAT IS THE BEST WAY TO REACH YOU?
Email Address
Contact Phone - -   Ext.

FEEDBACK
How did you find our Web site?
If other, please tell us how you found our Web site. 
What other services would you like to see provided from this Web site?
By submitting information, you certify that you are at least 18 years old.

 

©2003 University of Virginia Health System