Due to the COVID-19 pandemic UK HealthCare primary and specialty clinics are transitioning, when appropriate, to TeleCare visits. To request an appointment please fill out and submit our secure form. You will be contacted within 24 hours Mon.- Fri. to set up a TeleCare appointment. If you have an urgent care need, we are also offering 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 -Allergy & ImmunologyCardiovascular MedicineDentistryDermatologyDiabetes & EndocrinologyDigestive Health/GastroenterologyEar, Nose & Throat (ENT)EndoscopyFamily & Community MedicineGeneral & Vascular SurgeryGeorgetown Family Medicine & ObstetricsHematology and Blood & Marrow TransplantationI don't knowInfectious DiseaseInternal MedicineInterventional PainMarkey Cancer CenterNephrology, Bone & Mineral MetabolismNeurologyNeurosurgeryObstetrics & GynecologyOphthalmologyOrthopaedic Surgery & Sports MedicineOtherPediatric SurgeryPediatric Heart ProgramPediatricsPhysical Medicine & RehabilitationPlastic SurgeryPolk Dalton Primary CarePsychiatryPulmonaryRadiation OncologyRadiologyRheumatologyTeam Blue Primary Care ClinicTransplant CenterUniversity Health Service (UK Students or employees)UrologyWomen'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?