Request an Ultrasound Appointment

Thank you for requesting an ultrasound at one of Northwestern Lake Forest Hospital's five imaging locations.

Please complete the fields below and submit. Your request will go to a scheduler who will contact you by email or phone within one business day during regular business hours, Monday to Friday.

Please note: this appointment request is not for emergencies, same day or next day appointments. If you need an appointment within the next 48 hours, please contact us directly at 847.535.8000.

This appointment request form requires you to answer confidential health information that is needed to complete your request and shall be used only for the purpose of helping you secure an office visit. Your personal information will not be shared with any party outside of Northwestern Lake Forest Hospital.

*required information

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Date of Birth*

Day Phone*

Email*

How do you prefer we contact you?*

Email
Phone

Who is your primary care physician?*

Do you have a referral from your physician?*

Yes
No

Have you ever had an ultrasound at a Northwestern Lake Forest Hospital Imaging Center before?*

Yes
No

Preferred Location(s)
(Check all that apply.)*

Glenview
Grayslake
Gurnee Tower Court
Lake Forest
Libertyville Hollister Drive

Which time(s) of the day would you prefer your appointment?
(Check all that apply.)*

Morning (8:00 to 11:00 a.m.)
Noon (11:00 a.m. to 1:00 p.m.)
Afternoon (1:00 to 4:00 p.m.)
Evening (4:00 to 6:00 p.m.), when available

Which day(s) of the week would you prefer your appointment?
(Check all that apply.)*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (when available)
Sunday (when available)

Please provide any additional details about your request.

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