The University of Chicago

Request an Appointment

Please complete and submit the form below if you would like to request an appointment with one of our providers.
The office of Neurosurgery will receive the request directly and will give you a call within 24-48 hours.

Appointment Form

Appointment Request
Thank you for choosing UChicago Medicine. To start the appointment process, please complete and submit the form below. This form will be submitted directly to the office of Neurosurgery. We will then review the information received and call you regarding 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 scheduling an appointment, call the MHFP at (773) 795-0622.

Patient Demographics

Address *
Address
City
State/Province
Zip/Postal
Country
Please check to see if UChicago Medicine is in network with this insurance plan BEFORE requesting an appointment.

Diagnostic Information

Have you seen Neurosurgery at UChicago Medicine before? *
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 file 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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