Urology Appointment Request Form
Please expect a call back from a member of the scheduling team within 5 business days.
Patient Contact Information
Patient Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone or Landline?
*
Cell Phone
Landline
Unsure
Email Address
*
example@example.com
Date of Birth:
*
MM/DD/YYYY
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Insurance Information
Insurance Subscriber Full Name:
*
First Name
Last Name
Insurance/Plan Name:
*
Cigna, Blue Cross Blue Shield, etc.
Policy Number:
*
Appointment Information
What day of the week do you prefer?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Any Available
What time block do you prefer?
*
Morning (8 am - 10 am)
Late Morning (10 am -12 pm)
Mid-Afternoon (1-3 pm)
Later Afternoon (3-4:30 pm)
Any Available
Do you have a preference among providers and/or locations?
Katelyn Johnson, MD (Wakefield)
L. Eric Olsson, MD (Wakefield)
L. Eric Olsson, MD (Warwick)
L. Eric Olsson, MD (East Greenwich)
No preference
Soonest Available
Does your appointment concern any of the following? Check all that apply.
Urinary tract Infections
Urinary incontinence
Bladder disorders/overactive bladder
Kidney stones
Male infertility
Erectile dysfunction
Issues of the prostate
Vasectomy
Circumcision
Urologic cancers (prostate, bladder, kidney, testicular)
How did you hear about South County Health Urology?
*
Word of Mouth
TV/Radio
Email
Social Media
Google/Digital Ad
Print Publication
Streaming Service
Other
utm_source
utm_campaign
Marketing Communication: Are you interested in receiving email/SMS communication from South County Health?
Yes
No
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