Request an appointment | UK HealthCare

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class="side-menu__link-title">Blog</span> </a> </li> <li class="side-menu__item" > <a href="/extraordinary-people"> <span class="side-menu__link-title">Patient Stories</span> </a> </li> </ul> </div> </li> </ul> </div> </li> <li class="side-menu__item has-children" role="button" tabindex="0" > <div> <span class="side-menu__link-title">Contact</span> <i class="fas fa-angle-right"></i> <ul id="block-ukhc-main-menu" block="block-ukhc-main-menu" class="clearfix side-menu__items d-none"> <li class="side-menu__item" > <a href="/appointment"> <span class="side-menu__link-title">Request an Appointment</span> </a> </li> <li class="side-menu__item" > <a href="/patients-visitors/patients/medical-records"> <span class="side-menu__link-title">Medical Records</span> </a> </li> <li class="side-menu__item" > <a href="/daisy"> <span class="side-menu__link-title">Daisy Award Nomination Form</span> </a> </li> <li class="side-menu__item" > <a href="/awards-programs/bee-award-nominations"> <span class="side-menu__link-title">BEE Award Nomination Form</span> </a> </li> </ul> </div> </li> <li class="side-menu__item has-children" role="button" tabindex="0" > <div> <span class="side-menu__link-title">Community Commitment</span> <i class="fas fa-angle-right"></i> <ul id="block-ukhc-main-menu" block="block-ukhc-main-menu" class="clearfix side-menu__items d-none"> <li class="side-menu__item" > <a href="/community-commitment"> <span class="side-menu__link-title">Community Commitment</span> </a> </li> <li class="side-menu__item" > <a href="/wellness-community/ces"> <span class="side-menu__link-title">Cooperative Extension Service</span> </a> </li> <li class="side-menu__item" > <a href="/wellness-community/community-support"> <span class="side-menu__link-title">Community Resources</span> </a> </li> <li class="side-menu__item" > <a href="/office-opioid-safety"> <span class="side-menu__link-title">Office of Opioid Safety</span> </a> </li> <li class="side-menu__item" > <a href="/safe-kids-fayette-county"> <span class="side-menu__link-title">Safe Kids Fayette County</span> </a> </li> <li class="side-menu__item" > <a href="/digital"> <span class="side-menu__link-title">UKHC Digital Platforms</span> </a> </li> </ul> </div> </li> <li class="side-menu__item has-children" role="button" tabindex="0" > <div> <span class="side-menu__link-title">MyChart</span> <i class="fas fa-angle-right"></i> <ul id="block-ukhc-main-menu" block="block-ukhc-main-menu" class="clearfix side-menu__items d-none"> <li class="side-menu__item" > <a href="/mychart"> <span class="side-menu__link-title">Learn about MyChart</span> </a> </li> <li class="side-menu__item" > <a href="https://mychart.uky.edu/MyChart/Authentication/Login"> <span class="side-menu__link-title">Log in to MyChart</span> </a> </li> <li class="side-menu__item" > <a href="https://mychart.uky.edu/MyChart/signup"> <span class="side-menu__link-title">Request a MyChart account</span> </a> </li> <li class="side-menu__item" > <a href="/patients-visitors/portal/proxy"> <span class="side-menu__link-title">Proxy accounts</span> </a> </li> </ul> </div> </li> <li class="side-menu__item" > <a href="/doctors"> <span class="side-menu__link-title">Find a Doctor</span> </a> </li> <li class="side-menu__item" > <a href="/appointment"> <span class="side-menu__link-title">Appointment</span> </a> </li> </ul> </div> </div> <div class="side-menu" data-level="2" > <div class="side-menu__header"> <span class="side-menu__back" role="button" tabindex="-1" > <i class="fal fa-2x fa-angle-left"></i> Back </span> </div> <div class="side-menu__sub-header"> <h3></h3> <div class="ukhc__divider"></div> </div> <div class="side-menu__sub" tabindex="-1" ></div> </div> <div class="side-menu" data-level="3" > <div class="side-menu__header"> <span class="side-menu__back" role="button" tabindex="-1" > <i class="fal fa-2x fa-angle-left"></i> Back </span> </div> <div class="side-menu__sub-header"> <h3></h3> <div class="ukhc__divider"></div> </div> <div class="side-menu__sub" tabindex="-1" ></div> </div> </div> </section> <div class="patient-tools notransition-onresize"> <div class="patient-tools__item"> Request an <h4>Appointment</h4> <a href="/scheduling?source=patienttools" class="btn" > Request Appointment </a> </div> <div class="patient-tools__item"> Find a <h4>Doctor</h4> <a href="/search/#doctors" class="btn" > Search Doctors </a> </div> <div class="patient-tools__item"> Log in to <h4>MyChart</h4> <a href="https://mychart.uky.edu/" class="btn" > Login </a> </div> <small class="text-left"> <a href="/mychart" > Learn More </a> | <a href="/mychart#section-145206" > Request a Login </a> </small> </div> </div> </div> <div role="main" class="page page--webform"> <div> <div data-drupal-messages-fallback class="hidden"></div> </div> <section class="main-content" id="content" role="main"> <div class="onecol-container"> <h1 class="mt-3"> Request an appointment </h1> </div> <a id="main-content"></a> <div id="block-ukhc-content" class="block block-system block-system-main-block"> <div class="content"> <form class="webform-submission-form webform-submission-add-form webform-submission-request-an-appointment-form webform-submission-request-an-appointment-add-form js-webform-submit-once js-webform-autofocus js-webform-details-toggle webform-details-toggle" data-drupal-selector="webform-submission-request-an-appointment-add-form" action="/appointment" method="post" id="webform-submission-request-an-appointment-add-form" accept-charset="UTF-8"> <fieldset id="edit-intro" class="js-form-item js-form-type-webform-markup form-type-webform-markup js-form-item-intro form-item-intro form-no-label form-group"> <h2>Primary Care & Pharmacy Appointments</h2> <ul> <li><strong>New to UK HealthCare?</strong> Use our <a href="https://mychart.uky.edu/MyChart/OpenScheduling">Self- Scheduling</a> tool to find and book an appointment with a primary care provider.</li> <li><strong>Already have a MyChart account?</strong> Log in to <a href="https://mychart.uky.edu/MyChart/scheduling">MyChart</a> and schedule your next primary care appointment quickly.</li> <li><strong>Need to schedule a vaccination or point-of-care testing at a UK Retail Pharmacy location?</strong> Use the <a href="https://mychart.uky.edu/MyChart/OpenScheduling">Self- Scheduling</a> tool.</li> </ul> <h2>Specialist Appointments</h2> <p>Fill out and submit our secure form, and you will be contacted within 24 hours (Mon.-Fri.) to set up an appointment.</p> <h2>Other Scheduling Options</h2> <ul> <li><strong>Healthcare provider?</strong> Please use our referral form.</li> <li><strong>Emergency or mental health crisis:</strong> Call 911 or your physician. This form is not for urgent situations or medical advice.</li> <li><strong>Prefer to call?</strong> Dial 859-257-1000 or 800-333-8874 to schedule.</li> </ul> <p><em>Your privacy is important to us. We will only use your personal information in accordance with our Patient Notice of Privacy Practices.</em></p> </fieldset> <fieldset data-drupal-selector="edit-name" id="edit-name--wrapper" class="webform-name--wrapper fieldgroup form-composite webform-composite-hidden-title js-webform-type-webform-name webform-type-webform-name js-form-item form-item js-form-wrapper form-group"> <legend> <span class="visually-hidden fieldset-legend">Name</span> </legend> <div class="fieldset-wrapper"> <div class="webform-name"> <div class="webform-flexbox"> <div class="webform-flex webform-flex--3 webform-name__first"><div class="webform-flex--container"> <fieldset class="js-form-item js-form-type-textfield form-type-textfield js-form-item-name-first form-item-name-first form-group"> <label for="edit-name-first" class="js-form-required form-required">First</label> <input data-drupal-selector="edit-name-first" type="text" id="edit-name-first" name="name[first]" value="" size="60" maxlength="255" class="required form-control" required="required" aria-required="true" /> </fieldset> </div></div> <div class="webform-flex webform-flex--2 webform-name__middle"><div class="webform-flex--container"> <fieldset class="js-form-item js-form-type-textfield form-type-textfield js-form-item-name-middle form-item-name-middle form-group"> <label for="edit-name-middle">Middle</label> <input data-drupal-selector="edit-name-middle" type="text" id="edit-name-middle" name="name[middle]" value="" size="60" maxlength="255" class="form-control" /> </fieldset> </div></div> <div class="webform-flex webform-flex--3 webform-name__last"><div class="webform-flex--container"> <fieldset class="js-form-item js-form-type-textfield form-type-textfield js-form-item-name-last form-item-name-last form-group"> <label for="edit-name-last" class="js-form-required form-required">Last</label> <input data-drupal-selector="edit-name-last" type="text" id="edit-name-last" name="name[last]" value="" size="60" maxlength="255" class="required form-control" required="required" aria-required="true" /> </fieldset> </div></div> <div class="webform-flex webform-flex--1 webform-name__suffix"><div class="webform-flex--container"> <fieldset class="js-form-item js-form-type-textfield form-type-textfield js-form-item-name-suffix form-item-name-suffix form-group"> <label for="edit-name-suffix">Suffix</label> <input data-drupal-selector="edit-name-suffix" type="text" id="edit-name-suffix" name="name[suffix]" value="" size="60" maxlength="255" class="form-control" /> </fieldset> </div></div> </div> </div> </div> </fieldset> <fieldset class="js-form-item js-form-type-tel form-type-tel js-form-item-primary-phone-number form-item-primary-phone-number form-group"> <label for="edit-primary-phone-number" class="js-form-required form-required">Primary phone number</label> <input data-webform-required-error="Phone number is required." data-drupal-selector="edit-primary-phone-number" type="tel" id="edit-primary-phone-number" name="primary_phone_number" value="" size="30" maxlength="128" class="form-tel required form-control" required="required" aria-required="true" /> </fieldset> <fieldset data-drupal-selector="edit-mailing-address" id="edit-mailing-address--wrapper" class="webform-address--wrapper fieldgroup form-composite webform-composite-hidden-title js-webform-type-webform-address webform-type-webform-address js-form-item form-item js-form-wrapper form-group"> <legend> <span class="visually-hidden fieldset-legend">Mailing address</span> </legend> <div class="fieldset-wrapper"> <div class="webform-address"> <div class="webform-flexbox webform-address__row-1"> <div class="webform-flex webform-flex--1 webform-address__address"><div class="webform-flex--container"> <fieldset class="js-form-item js-form-type-textfield form-type-textfield js-form-item-mailing-address-address form-item-mailing-address-address form-group"> <label for="edit-mailing-address-address" class="js-form-required form-required">Address</label> <input data-drupal-selector="edit-mailing-address-address" type="text" id="edit-mailing-address-address" name="mailing_address[address]" value="" size="60" maxlength="255" class="required form-control" required="required" aria-required="true" /> </fieldset> </div></div> </div> <div class="webform-flexbox webform-address__row-2"> <div class="webform-flex webform-flex--1 webform-address__address-2"><div class="webform-flex--container"> <fieldset class="js-form-item js-form-type-textfield form-type-textfield js-form-item-mailing-address-address-2 form-item-mailing-address-address-2 form-group"> <label for="edit-mailing-address-address-2">Address 2</label> <input data-drupal-selector="edit-mailing-address-address-2" type="text" id="edit-mailing-address-address-2" name="mailing_address[address_2]" value="" size="60" maxlength="255" class="form-control" /> </fieldset> </div></div> </div> <div class="webform-flexbox webform-address__row-3"> <div class="webform-flex webform-flex--1 webform-address__city"><div class="webform-flex--container"> <fieldset class="js-form-item js-form-type-textfield form-type-textfield js-form-item-mailing-address-city form-item-mailing-address-city form-group"> <label for="edit-mailing-address-city" class="js-form-required form-required">City/Town</label> <input data-drupal-selector="edit-mailing-address-city" type="text" id="edit-mailing-address-city" name="mailing_address[city]" value="" size="60" maxlength="255" class="required form-control" required="required" aria-required="true" /> </fieldset> </div></div> <div class="webform-flex webform-flex--1 webform-address__province"><div class="webform-flex--container"> <fieldset class="js-form-item js-form-type-select form-type-select js-form-item-mailing-address-state-province form-item-mailing-address-state-province form-group"> <label for="edit-mailing-address-state-province" class="js-form-required form-required">State/Province</label> <select data-drupal-selector="edit-mailing-address-state-province" id="edit-mailing-address-state-province" name="mailing_address[state_province]" class="form-select required form-control custom-select" required="required" aria-required="true"><option value="" selected="selected">- Select -</option><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="American Samoa">American Samoa</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="Armed Forces (Canada, Europe, Africa, or Middle East)">Armed Forces (Canada, Europe, Africa, or Middle East)</option><option value="Armed Forces Americas">Armed Forces Americas</option><option value="Armed Forces Pacific">Armed Forces Pacific</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="District of Columbia">District of Columbia</option><option value="Federated States of Micronesia">Federated States of Micronesia</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Guam">Guam</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Marshall Islands">Marshall Islands</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Northern Mariana Islands">Northern Mariana Islands</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Palau">Palau</option><option value="Pennsylvania">Pennsylvania</option><option value="Puerto Rico">Puerto Rico</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virgin Islands">Virgin Islands</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option><option value="Alberta">Alberta</option><option value="British Columbia">British Columbia</option><option value="Manitoba">Manitoba</option><option value="New Brunswick">New Brunswick</option><option value="Newfoundland and Labrador">Newfoundland and Labrador</option><option value="Nova Scotia">Nova Scotia</option><option value="Northwest Territories">Northwest Territories</option><option value="Nunavut">Nunavut</option><option value="Ontario">Ontario</option><option value="Prince Edward Island">Prince Edward Island</option><option value="Quebec">Quebec</option><option value="Saskatchewan">Saskatchewan</option><option value="Yukon">Yukon</option></select> </fieldset> </div></div> <div class="webform-flex webform-flex--1 webform-address__postal-code"><div class="webform-flex--container"> <fieldset class="js-form-item js-form-type-textfield form-type-textfield js-form-item-mailing-address-postal-code form-item-mailing-address-postal-code form-group"> <label for="edit-mailing-address-postal-code" class="js-form-required form-required">ZIP/Postal Code</label> <input data-drupal-selector="edit-mailing-address-postal-code" type="text" id="edit-mailing-address-postal-code" name="mailing_address[postal_code]" value="" size="60" maxlength="255" class="required form-control" required="required" aria-required="true" /> </fieldset> </div></div> </div> </div> </div> </fieldset> <fieldset id="edit-email-address" class="webform-email-confirm--wrapper fieldgroup form-composite webform-composite-hidden-title js-webform-type-webform-email-confirm webform-type-webform-email-confirm js-form-item form-item js-form-wrapper form-group"> <legend> <span class="visually-hidden fieldset-legend">Email address</span> </legend> <div class="fieldset-wrapper"> <fieldset class="js-form-item js-form-type-email form-type-email js-form-item-email-address-mail-1 form-item-email-address-mail-1 form-group"> <label for="edit-email-address-mail-1" class="js-form-required form-required">Email address</label> <input data-webform-required-error="Email address is required." data-drupal-selector="edit-email-address-mail-1" class="webform-email form-email required form-control" type="email" id="edit-email-address-mail-1" name="email_address[mail_1]" value="" size="60" maxlength="254" required="required" aria-required="true" /> </fieldset> <fieldset class="js-form-item js-form-type-email form-type-email js-form-item-email-address-mail-2 form-item-email-address-mail-2 form-group"> <label for="edit-email-address-mail-2" class="js-form-required form-required">Please retype email address.</label> <input data-webform-required-error="Email address is required." data-drupal-selector="edit-email-address-mail-2" class="webform-email-confirm form-email required form-control" type="email" id="edit-email-address-mail-2" name="email_address[mail_2]" value="" size="60" maxlength="254" required="required" aria-required="true" /> </fieldset> </div> </fieldset> <fieldset data-drupal-selector="edit-patient-gender" id="edit-patient-gender--wrapper" class="radios--wrapper fieldgroup form-composite webform-composite-visible-title js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-group"> <legend id="edit-patient-gender--wrapper-legend"> <span class="fieldset-legend">Patient gender</span> </legend> <div class="fieldset-wrapper"> <div id="edit-patient-gender" class="js-webform-radios webform-options-display-one-column radio"> <div class="js-form-item js-form-type-radio radio form-check js-form-item-patient-gender form-item-patient-gender"> <input data-drupal-selector="edit-patient-gender-male" type="radio" id="edit-patient-gender-male" name="patient_gender" value="Male" class="form-radio form-check-input"> <label class="form-check-label" for="edit-patient-gender-male"> Male </label> </div> <div class="js-form-item js-form-type-radio radio form-check js-form-item-patient-gender form-item-patient-gender"> <input data-drupal-selector="edit-patient-gender-female" type="radio" id="edit-patient-gender-female" name="patient_gender" value="Female" class="form-radio form-check-input"> <label class="form-check-label" for="edit-patient-gender-female"> Female </label> </div> <div class="js-form-item js-form-type-radio radio form-check js-form-item-patient-gender form-item-patient-gender"> <input data-drupal-selector="edit-patient-gender-do-not-wish-to-disclose" type="radio" id="edit-patient-gender-do-not-wish-to-disclose" name="patient_gender" value="Do not wish to disclose" class="form-radio form-check-input"> <label class="form-check-label" for="edit-patient-gender-do-not-wish-to-disclose"> Do not wish to disclose </label> </div> </div> </div> </fieldset> <fieldset class="js-form-item js-form-type-datelist form-type-datelist js-form-item-date-of-birth form-item-date-of-birth form-group"> <label class="js-form-required form-required">Date of birth</label> <div id="edit-date-of-birth" class="container-inline form-inline"> <fieldset class="js-form-item js-form-type-select form-type-select js-form-item-date-of-birth-month form-item-date-of-birth-month form-group"> <label for="edit-date-of-birth-month" class="js-form-required form-required">Date of birth: Month</label> <select data-webform-required-error="Date of birth is required." data-drupal-selector="edit-date-of-birth-month" title="Month" id="edit-date-of-birth-month" name="date_of_birth[month]" class="form-select required form-control custom-select" required="required" aria-required="true"><option value="" selected="selected">Month</option><option value="1">Jan</option><option value="2">Feb</option><option value="3">Mar</option><option value="4">Apr</option><option value="5">May</option><option value="6">Jun</option><option value="7">Jul</option><option value="8">Aug</option><option value="9">Sep</option><option value="10">Oct</option><option value="11">Nov</option><option value="12">Dec</option></select> </fieldset> <fieldset class="js-form-item js-form-type-select form-type-select js-form-item-date-of-birth-day form-item-date-of-birth-day form-group"> <label for="edit-date-of-birth-day" class="js-form-required form-required">Date of birth: Day</label> <select data-webform-required-error="Date of birth is required." data-drupal-selector="edit-date-of-birth-day" title="Day" id="edit-date-of-birth-day" name="date_of_birth[day]" class="form-select required form-control custom-select" required="required" aria-required="true"><option value="" selected="selected">Day</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select> </fieldset> <fieldset class="js-form-item js-form-type-select form-type-select js-form-item-date-of-birth-year form-item-date-of-birth-year form-group"> <label for="edit-date-of-birth-year" class="js-form-required form-required">Date of birth: Year</label> <select data-webform-required-error="Date of birth is required." data-drupal-selector="edit-date-of-birth-year" title="Year" id="edit-date-of-birth-year" name="date_of_birth[year]" class="form-select required form-control custom-select" required="required" aria-required="true"><option value="" selected="selected">Year</option><option value="1900">1900</option><option value="1901">1901</option><option value="1902">1902</option><option value="1903">1903</option><option value="1904">1904</option><option value="1905">1905</option><option value="1906">1906</option><option value="1907">1907</option><option value="1908">1908</option><option value="1909">1909</option><option value="1910">1910</option><option value="1911">1911</option><option value="1912">1912</option><option value="1913">1913</option><option value="1914">1914</option><option value="1915">1915</option><option value="1916">1916</option><option value="1917">1917</option><option value="1918">1918</option><option value="1919">1919</option><option value="1920">1920</option><option value="1921">1921</option><option value="1922">1922</option><option value="1923">1923</option><option value="1924">1924</option><option value="1925">1925</option><option value="1926">1926</option><option value="1927">1927</option><option value="1928">1928</option><option value="1929">1929</option><option value="1930">1930</option><option value="1931">1931</option><option value="1932">1932</option><option value="1933">1933</option><option value="1934">1934</option><option value="1935">1935</option><option value="1936">1936</option><option value="1937">1937</option><option value="1938">1938</option><option value="1939">1939</option><option value="1940">1940</option><option value="1941">1941</option><option value="1942">1942</option><option value="1943">1943</option><option value="1944">1944</option><option value="1945">1945</option><option value="1946">1946</option><option value="1947">1947</option><option value="1948">1948</option><option value="1949">1949</option><option value="1950">1950</option><option value="1951">1951</option><option value="1952">1952</option><option value="1953">1953</option><option value="1954">1954</option><option value="1955">1955</option><option value="1956">1956</option><option value="1957">1957</option><option value="1958">1958</option><option value="1959">1959</option><option value="1960">1960</option><option value="1961">1961</option><option value="1962">1962</option><option value="1963">1963</option><option value="1964">1964</option><option value="1965">1965</option><option value="1966">1966</option><option value="1967">1967</option><option value="1968">1968</option><option value="1969">1969</option><option value="1970">1970</option><option value="1971">1971</option><option value="1972">1972</option><option value="1973">1973</option><option value="1974">1974</option><option value="1975">1975</option><option value="1976">1976</option><option value="1977">1977</option><option value="1978">1978</option><option value="1979">1979</option><option value="1980">1980</option><option value="1981">1981</option><option value="1982">1982</option><option value="1983">1983</option><option value="1984">1984</option><option value="1985">1985</option><option value="1986">1986</option><option value="1987">1987</option><option value="1988">1988</option><option value="1989">1989</option><option value="1990">1990</option><option value="1991">1991</option><option value="1992">1992</option><option value="1993">1993</option><option value="1994">1994</option><option value="1995">1995</option><option value="1996">1996</option><option value="1997">1997</option><option value="1998">1998</option><option value="1999">1999</option><option value="2000">2000</option><option value="2001">2001</option><option value="2002">2002</option><option value="2003">2003</option><option value="2004">2004</option><option value="2005">2005</option><option value="2006">2006</option><option value="2007">2007</option><option value="2008">2008</option><option value="2009">2009</option><option value="2010">2010</option><option value="2011">2011</option><option value="2012">2012</option><option value="2013">2013</option><option value="2014">2014</option><option value="2015">2015</option><option value="2016">2016</option><option value="2017">2017</option><option value="2018">2018</option><option value="2019">2019</option><option value="2020">2020</option><option value="2021">2021</option><option value="2022">2022</option><option value="2023">2023</option><option value="2024">2024</option><option value="2025">2025</option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option><option value="2036">2036</option><option value="2037">2037</option><option value="2038">2038</option><option value="2039">2039</option><option value="2040">2040</option><option value="2041">2041</option><option value="2042">2042</option><option value="2043">2043</option><option value="2044">2044</option><option value="2045">2045</option><option value="2046">2046</option><option value="2047">2047</option><option value="2048">2048</option><option value="2049">2049</option><option value="2050">2050</option></select> </fieldset> </div> </fieldset> <fieldset class="js-form-item js-form-type-select form-type-select js-form-item-clinic-or-service form-item-clinic-or-service form-group"> <label for="edit-clinic-or-service" class="js-form-required form-required">Clinic or service</label> <select data-webform-required-error="You must select a clinic or service." data-drupal-selector="edit-clinic-or-service" id="edit-clinic-or-service" name="clinic_or_service" class="form-select required form-control custom-select" required="required" aria-required="true"><option value="" selected="selected">- Select -</option><option value="Adolescent Medicine">Adolescent Medicine</option><option value="Aesthetics Center">Aesthetics Center</option><option value="Allergy">Allergy</option><option value="Behavioral Health - UK Students Only">Behavioral Health - UK Students Only</option><option value="Cardiology">Cardiology</option><option value="Dentistry">Dentistry</option><option value="Diabetes/Endocrinology">Diabetes/Endocrinology</option><option value="Digestive Health/Gastroenterology">Digestive Health/Gastroenterology</option><option value="Endoscopy">Endoscopy</option><option value="ENT">ENT/Ear, Nose & Throat</option><option value="Eye Care/Ophthalmology">Eye Care/Ophthalmology</option><option value="Family Care Center">Family Care Center</option><option value="Hand Center">Hand Center</option><option value="Hematology">Hematology Program – Markey Cancer Center </option><option value="Infectious Disease">Infectious Disease</option><option value="Internal Medicine Group">Internal Medicine Group</option><option value="Interventional Pain Medicine">Interventional Pain Medicine</option><option value="Joint Heart Program">Joint Heart Program</option><option value="Nephrology/Bone and Mineral">Nephrology/Bone & Mineral</option><option value="Neurology">Neurology</option><option value="Neurosurgery">Neurosurgery</option><option value="Nutrition">Nutrition</option><option value="OB/GYN - Georgetown">OB/GYN - Georgetown</option><option value="OB/GYN - Good Samaritan">OB/GYN - Good Samaritan</option><option value="OB/GYN - Polk Dalton">OB/GYN - Polk Dalton</option><option value="Orthopaedic Surgery and Sports Medicine - Good Samaritan">Orthopaedic Surgery & Sports Medicine - Good Samaritan</option><option value="Orthopaedic Surgery and Sports Medicine – Kentucky Clinic">Orthopaedic Surgery & Sports Medicine – Kentucky Clinic</option><option value="Other or unsure">Other or unsure</option><option value="Pediatric Surgery">Pediatric Surgery</option><option value="Pediatrics - General">Pediatrics - General</option><option value="Pediatrics - Specialty">Pediatrics - Specialty</option><option value="Physical Medicine and Rehabilitation">Physical Medicine & Rehabilitation</option><option value="Plastic/Cosmetic Surgery">Plastic/Cosmetic Surgery</option><option value="Primary Care - Georgetown Family Medicine">Primary Care - Georgetown Family Medicine</option><option value="Primary Care - Polk Dalton">Primary Care - Polk Dalton</option><option value="Primary Care - Team Blue/Employee">Primary Care - Team Blue/Employee</option><option value="Primary Care – Turfland Family & Community Medicine ">Primary Care - Turfland Family & Community Medicine </option><option value="Psychiatry">Psychiatry</option><option value="Pulmonary">Pulmonary</option><option value="Radiology">Radiology</option><option value="Rheumatology">Rheumatology</option><option value="Sports Medicine - Turfland">Sports Medicine - Turfland</option><option value="Student Health - UK Students Only">Student Health - UK Students Only</option><option value="Surgery - General and Vascular">Surgery - General & Vascular</option><option value="Transform Health">Transform Health</option><option value="Urgent Care">Urgent Care</option><option value="Urology">Urology</option><option value="Women's Health">Women's Health</option><option value="Wound Care">Wound Care</option></select> </fieldset> <fieldset class="js-form-item js-form-type-textfield form-type-textfield js-form-item-provider-you-wish-to-see form-item-provider-you-wish-to-see form-group"> <label for="edit-provider-you-wish-to-see">Provider you wish to see</label> <div class="description"> <div id="edit-provider-you-wish-to-see--description" class="webform-element-description">If you would like to see a specific provider please type their name here.</div> </div> 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