Due to the COVID-19 pandemic UK HealthCare primary and specialty clinics are now offering both in-person and TeleCare visits. To request an appointment please fill out and submit our secure form. You will be contacted within 24 hours Monday-Friday to set up an appointment. If you have an urgent care need, we are also offering in-person urgent care and UK Urgent Telecare. Fill out and submit our secure form and you will be contacted within 24 hours Mon.- Fri. to set up an appointment. Already a patient? Please use the My UKHealthCare Patient Portal. Healthcare provider? Please use our referral form. Emergency or mental health crisis: call 911 or your physician. (this form is not for urgent situations or medical advice.) If you prefer, call 859-257-1000 or 800-333-8874 to schedule, or cancel using our cancellation form. Your privacy is important to us. We will only use your personal information consistent with our Patient Notice of Privacy Practices. Name First Middle Last Suffix Primary phone number Mailing address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Email address Email address Please retype email address. Patient gender Male Female Do not wish to disclose Date of birth Date of birth: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date of birth: Day Day12345678910111213141516171819202122232425262728293031 Date of birth: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Clinic or service - Select -Adolescent MedicineAllergyCardiologyDentistryDiabetes/EndocrinologyDigestive Health/GastroenterologyEndoscopyENT/Ear, Nose & ThroatEye Care/OphthalmologyFamily Care CenterHematology Program – Markey Cancer Center Infectious DiseaseInternal Medicine GroupInterventional Pain AssociatesNephrology/Bone & MineralNeurologyNeurosurgeryNutritionOB/GYN - GeorgetownOB/GYN - Good SamaritanOB/GYN - Polk DaltonOrthopaedic Surgery & Sports Medicine - Good SamaritanOrthopaedic Surgery & Sports Medicine – Kentucky ClinicOther or unsurePediatric Heart ProgramPediatric SurgeryPediatrics - GeneralPediatrics - SpecialtyPhysical Medicine & RehabilitationPlastic SurgeryPrimary Care - Georgetown Family MedicinePrimary Care - Polk DaltonPrimary Care - Team Blue/EmployeePrimary Care - Turfland Family & Community Medicine PsychiatryPulmonaryRadiologyRheumatologySports Medicine - TurflandSurgery - General & VascularTransform HealthUHS/University Health ServiceUrgent CareUrologyWomen's HealthWound Care Provider you wish to see If you would like to see a specific provider please type their name here. Referring provider's name Please type the name of your current or referring healthcare provider. Referring provider's city Please type the name of the city and state where your current or referring healthcare provider is located. How did you hear about us?