The University of Chicago

Request an Appointment

Appointment Request (National Expert)
To request an appointment with one of our national experts, please select the appropriate provider and submit the form below. This information will be reviewed by the selected provider's office who will call you in regards to scheduling an appointment.
• Please attach pertinent medical records, including test results and imaging, that support the diagnosis.
• Please attach a copy of the patient’s insurance card (both sides) and HMO authorization, if required.

For help requesting an appointment with one of our national experts, call us at (773) 795-0622.

Patient Demographics

Address *
Address
City
State/Province
Zip/Postal
Country
Please check to see if this insurance is in-network with the physician's facility BEFORE requesting an appointment.

Diagnostic Information

Have you had prior neurosurgery (brain or spine surgery)? *
When did you have neurosurgery?
If you have not had any imaging pertaining to the diagnosis (such as CT, MRI, or X-ray scans), please enter "None".
Are you being referred to neurosurgery by your doctor? *

Referring Provider Information

Address
Address
City
State/Province
Zip/Postal
Country
File Upload
Maximum upload size: 52.22MB
Please upload pertinent medical records, including test results and imaging (CT, MRI, Xray, etc.) that support the diagnosis. Please also upload a copy of the patient’s insurance card (both sides) and HMO authorization, if required.

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