Request An Appointment - UH Health

* = Required Field

Select Your Location *

Patient Is *

A New Patient

An Existing Patient

Is the Patient a UH employee or student? *

A Student

Faculty or Staff

Not A Employee or Student

First Name *

Last Name *

Date of Birth *

Patient Gender *

Male

Female

Address *

Apt *

City *

State *

Zip *

Daytime Phone *

Cell / Alternate Phone

Email Address *

What type of appointment would you like? *

Complete Eye Exam (Glasses)

Complete Eye Exam (Contact Lenses)

Complete Eye Exam (Glasses & Contact Lenses)

Other

When would you like the appointment? *

Next Available

Sometime Next Week (Apr 29th - May 03rd)

Sometime in the Next Two Weeks (Apr 29th - May 10th)

Other

Preferred Appointment Time? *

Morning

Afternoon

No Preference

How did you hear about us? *