Request an Appointment

myLoyola Users

If you are a member of myLoyola, please sign in now. Your contact information in the form below will be completed for you automatically. Learn more about myLoyola.

Online Appointment Request

Please complete the form below to submit a request for an appointment with a primary care physician. After you submit a request, you will receive a call from a representative at the selected location within two business days to confirm your information and schedule the appointment. If you are a parent making an a request for your child, please put your child's information in the 'Patient' section and your name in the 'Contact Person section'.

If you require a more immediate appointment for an illness, call the primary care center directly.

Please note: This form is used for requesting appointments for primary care physicians only. To make an appointment with a Loyola specialist, please call (708) 216-8563.

If this is an emergency, please call 911 immediately.

* Denotes required field
Patient name:
*	Last name:
	Middle initial:
*	First name:
*	Gender:
*	Birth date: (mm/dd/yyyy)
*	Street address:
	Apartment,Unit:
*	City:
*	State:
*	ZIP code:
*	Primary phone: (xxx-xxx-xxxx)
	Alternate phone: (xxx-xxx-xxxx)
*	Best time to reach you at your primary phone #:
	E-mail address:
Contact person (if different from patient):
	Name:
	Primary phone: (xxx-xxx-xxxx)
	Alternate phone: (xxx-xxx-xxxx)
	Best time to reach you:
Appointment details
*	Primary care site:
*	Reason for appointment:
	Requested physician:
*	Have you seen this physician before?:
*	Are you a Loyola patient?:
Indicate preferred date and time of the appointment:
*	Preferred appointment day:
*	Preferred appointment time:
*	Please indicate which is most important to you:	Please note: When the representative calls you to schedule the appointment, she/he will give you the options available that best meet your needs.

Request an Appointment

myLoyola Users

Online Appointment Request

Patient name:

Contact person (if different from patient):

Appointment details

Indicate preferred date and time of the appointment: