New Patient Appointment Request

Patients new to Memorial Health University Physicians (MHUP) may use this form to request an appointment with any of our primary care providers or specialists.

Already an MHUP patient? Request an appointment through MyChart or call your doctor’s office directly.

To sign up for MyChart, enter the access code you received on the paperwork from your last visit. Or, call your doctor’s office to get an access code.

Do not use this form for a medical emergency. If you are experiencing an emergency, dial 911.

Required fields are marked with an *
Patient name*  
Patient birthday*  
Address*  
City and zip code*  
Phone number*  
Alternate phone number
Email address  
Specialty or doctor requested*  
Insurance Information:
     Name of carrier*  
     Group ID*  
     Member ID*  
Date and time preferred*