Request an Appointment — University Urology

Use this form if you are a new patient requesting urology care. If you have seen a University Urology provider before, use the existing patient request link above.

Your Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Insurance Plan Name *

Member ID

Group Number

You may also upload a photo of your insurance card below. If you don't have this information handy, our team will collect it when we call.

How Did You Hear About Us?

How did you hear about us?

Details, if you remember

Reason for Visit

Primary Concern *

⚕ A few quick questions to help us prioritize your care

City / State

Location Preference

Preferred Day of Week

Preferred Time of Day

Additional Symptoms or Details

Documents & Imaging

📎

Attach lab results, imaging reports, or insurance card photo

PDF, JPG, PNG, HEIC · Max 20 MB

Imaging Notice: Imaging (CT scan, ultrasound, X-ray, or MRI) is often needed for urologic conditions. If you know where imaging was done, list it above. If you have a report, upload it here or bring it to your appointment.

📄

Message Us on Klara

This form is transmitted over an encrypted (HTTPS) connection. Your information is protected health information and will only be used to schedule your appointment. Privacy Policy

✅

Request Received

Thank you — your appointment request has been received. Our scheduling team will be in touch to confirm your appointment.

If this is a medical emergency, please call 911 or go to your nearest emergency room.

Your confirmation number:

Please save this number for your records.

Questions? Call us at 865-305-9254

Patient Self-Referral