Online Appointment Request

If this is an emergency, please call 911 immediately.

Please complete the form below to submit a request for an appointment with a 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 a request for your child, please put your child's information in the 'Patient Information' section and your name in the 'Contact Information' section.

If you require a more immediate appointment for an illness, call (888) LUHS-888 (888-584-7888).

* required field

Contact Information

Name *
E-mail address
Primary phone *
()
Alternate phone
()
Best time to contact *
Appointment for you or someone else? *
Me Someone else

Patient Information

Patient first name *
Patient middle name
Patient last name *
Gender *
Female Male
Date of birth *
Address line 1 *
Address line 2
City *
State *
Zip code *

Appointment Details

Requested physician
Reason for appointment *
Preferred appointment day *
Preferred appointment time *
Indicate which is more important *
First time seeing this physician *
Yes No N/A
Are you a Loyola patient *
Yes No
Enter Submission Code*
Type the characters you see


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