New Patient Appointment Request Form

Please do not schedule an appointment if you have recently traveled to a country identified as high risk by the CDC or have been in contact with someone who has been confirmed to have COVID-19 (coronavirus) and you have a fever and/or respiratory symptoms. Instead, call us during normal business hours. Find the latest information about COVID-19 here.

This Schedule an Appointment form is for non-urgent appointments only. If this is a medical emergency and you are in need of immediate care, please dial 911 or go to your nearest emergency room or facility.

To complete this form you need:

  • Patient’s health insurance plan information
  • Name and date of birth of the health insurance subscriber

After submitting the form, you will be contacted within 1-2 business days. If you require assistance sooner call 1.844.344.6663.

  • 1. Patient Info
  • 2. Insurance
  • 3. Scheduling
  • 4. Submit
Patient Information
Insurance Information

Does the patient have health insurance?

Appointment Preferences

What type of care is needed?

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Best Day and Time for Appointment

How would you like to receive your appointment information?

Submission

By completing and submitting this form, you consent to your information being disclosed to the physician and his/her office staff.

For more information about how your information is collected, used and protected by Northwestern Medicine, please visit our Website Terms of Use and Privacy Policy.

Legal Information
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The appointment request form requires you to provide confidential health information that will be utilized only for the purpose of helping you secure an office visit with a Northwestern Medicine affiliated physician.