Please provide the following information for all patients being referred to UAMS. The Appointment Center will schedule an appointment and notify you of the time and date as quickly as possible. In order to process the appointment all of the information below must be included with your appointment request. You will not be able to submit your request until all fields (areas) are completed.
Telephone: 501-686-8000
or FAX 501-686-8504

Physician Information To check or change your information Click on the link to the Physician Referral Office

Patient Information

Last name
First name
Middle initial
Street address
Zip code -
Home telephone number including area code
( ) -
Daytime telephone number including area code ( ) -
Date of birth Month Day Year
Social security number - -
Emergency contact number
Emergency contact Name/Relation
Does the patient have insurance? Yes    No
Insurance Provider
Medicaid number
Medicare number
 A    B    A & B
Specialty clinic requested
Diagnosis (or reason for referral)
Name of person completing form

Physician Information

Enter the first few letters of the physician's last name. Then select the Referring physician from the dropdown list.
Referring physician last name
Referring physician first name
Referring Physician phone number
Referring Physician Fax number
Referring Physician Beeper number
Referring Physician Home number
Referring address
Additional Referring address
Referring city
Referring state
Referring zip code
Referring email address
Enter the first few letters of the physician's last name. Then select the Primary Care physician from the dropdown list.
Primary care physician last name
Primary care physician first name
Please call physician's office with appointment information  Yes No

If an e-mail address is available and you prefer us to inform you of the patient appointment by e-mail, please provide your email address:
Notification e-mail address
Comments to the Appointment Center

Fax records to 501-686-8504 attention Appointment Center.  Appointment will NOT be scheduled until records have been received!

Patient will receive packet in the mail from UAMS advising them of appointment date and time.

Physician referral services