Request a Wound Center Appointment

We are happy to schedule appointments for new and returning patients via this online form. Please complete the fields below and submit. We will contact you within one business day to confirm your appointment.

First Name*

Last Name*

Address*

City*

State*

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Zip Code*

Date of Birth*

Day Phone*

Email*

Who is your primary care physician?*

Has your physician written you a referral to the Wound Center?*

-Select- Yes No

Are you a new or returning patient to the Wound Center*

-Select- New Returning

What time of day do you prefer your appointment? (Please check all that apply.)*

Morning (8:00 - 11:00am)
Noon (11:00am - 1:00pm)
Afternoon (1:00 - 4:00pm)

What day of the week do you prefer your appointment? (Please check all that apply.)*

Monday
Tuesday
Wednesday
Thursday
Friday

Please describe your health concerns or symptoms.

How did you hear about the Northwestern Lake Forest Hospital Wound Center?*

-Select- My physician Web search Friend Advertisement Other

Would you like to receive the eNewsletter and/or mailings from Lake Forest Hospital?*

-Select- Yes No