Online Appointment Request Form

You may complete the form below to request an appointment at a Cleveland Clinic location.

For insured patients, please fill out all relevant insurance fields. For non-insured patients, please call to schedule an appointment.

Please note that your request will be processed within 1-2 business days. If you are experiencing a medical emergency, please call 911.

Information on this page is secure. We value your privacy.
* Indicates a required field.

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Patient Information

The person who will be seeing the physician.

Ex. (mm/dd/yyyy)
25 characters maximum. Use Address Line 2 if more room is needed.
25 characters maximum.

Appointment Details

Has the patient been seen at Cleveland Clinic in the past?

As part of a national initiative, we ask for a patient's race, ethnicity and language to help us deliver high quality health care equally to all patients.

How would you like to have us list the patient's race on the medical record?
How would you like to have us list the patient's ethnicity on the medical record?
If primary language is other than English, should interpreter be scheduled for appointment?
Is the patient hearing impaired?
If patient is hearing impaired, should sign language interpreter be scheduled for appointment?
Does the patient have a diagnosis?
Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.) 500 characters maximum.
Is this condition or injury related to work?
Is this condition or injury related to an auto accident?
Preferred day of the week / date / time of day or first available.
Preferred physician or provider name.
We cannot guarantee exact scheduling, but we will do our best to accommodate the patient's wishes.

Requestor Information

The person completing this form.

Phone Type
Are you over 18?
Would you like to receive health-related mailings from us?

Referring Physician Information

Patient Referred by outside Physician?
Is this physician also the patient's Primary Care Provider?

Primary Health Insurance Information

All fields are required unless noted as optional.

Does the patient have health insurance?

Please provide insurance information as it appears on the insurance card.

Product Type

Policy Holder Information:

Secondary Health Insurance Information

Does the patient have secondary insurance?
Product Type

Secondary Subscriber or Policy Holder Information

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