PRIVACY/SECURITY ACKNOWLEDGEMENT NOTICE

The online appointment request form requires you to enter personally identifying information (name, phone number, etc.). Once you enter and submit the information, it is transmitted to a secure location for processing; however, we cannot guarantee the security of your information during transmission. The protection of your personal information and your privacy is a priority of UCHC. If UCHC becomes aware of a data security breach involving the online appointment request function, you will be notified as immediately as possible. By pressing the “Continue” button below, you are expressing acknowledgement of the information above and an informed decision to continue with the online appointment request..

To set up an appointment request, please fill out the information below, If you prefer please call 617-287-8000 and a staff member will assist you.





State





Date Of Birth


Your Health Insurance Information


Insurance:


Additional Information


Reason for visit:

Note: Please call us at 617-287-8000 if you need to schedule an appointment within three days

Preferred Appointment Day and Time:


Alternate Preferred Day and Time:


Preferred Medical Specialty: