Secure Patient Portal

Request an Appointment

Tell us about your concerns and we'll match you with the right provider. Our scheduling team will be in touch to confirm your appointment.

Have you seen us before?

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Yes — I'm an Existing Patient

I've seen a provider here before

Provider referring a patient? Use the provider referral form →

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.

Reason for Visit

Primary Concern *

⚕ A few quick questions to help us prioritize your care

City / State

Location Preference

Additional Symptoms or Details

Documents & Imaging

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Attach lab results, imaging reports, or insurance card photo

PDF, JPG, PNG · Max 20 MB

📷 Imaging Notice: Imaging (CT scan, ultrasound, X-ray, or MRI) is required to be seen for most urologic conditions. If you have recent imaging, please upload the report above or bring the images to your appointment. If you do not have imaging, our team will advise you on next steps when we call.

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🔒 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

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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