Request An Appointment with Eye Institute

If this is an emergency, please call 911

If you already have UW Medicine eCare access log in here to request an appointment with your provider.

If you are a new patient, or do not have UW Medicine eCare access, please fill out the form below to request an appointment with one of our physicians. Please complete as many of the fields as possible.

Once you have completed and submitted the form, a clinical representative will contact you to set a date and time for your appointment.

If you have any questions or difficulties, please feel free to contact us at 206.520.5000.

Please fill in the following information. *Denotes a required field.

*Name (first and last):

*Best Phone during business hours:	Extension:

*Email:

*Confirm Email Address:


Zip Code:
City:

State:

Please fill in the following information. *Denotes a required field.

The patient's name, phone and email are the same as above.
*Name (first and last):

*Best Phone during business hours:	Extension:

*Email:

Birth Date: (mm/dd/yyyy)



*Has the patient ever received treatment at UW Medicine?	YesNo

*Does the patient have insurance?	YesNo

What is the patient's Primary Insurance?
Primary Care Physician:
Does the patient have secondary insurance?	YesNo
What is the patient's Secondary Insurance?

Reason for request or diagnosis (If Known):

Please fill in the following information. *Denotes a required field.

Referring Physician (if applicable):
Doctor You Are Requesting:
How did you hear about us?
Please specify how you heard about us.

When would you like to be seen? (We will make every attempt to accommodate morning or afternoon preferences, and schedule your appointment within the requested time frame.):

Risks of using e-mail

UW Medicine providers and staff will use reasonable means to protect the security and confidentiality of any information sent and received by e-mail. Patients should understand that there are known and unknown risks that may affect the privacy of personal health care information when using e-mail to communicate. Those risks include, but are not limited, to:

E-mail may be forwarded, printed, and stored in numerous paper and electronic forms and be received by many intended and unintended recipients without a patient�s knowledge or agreement.
E-mail may be sent to the wrong address by any sender or receiver.
E-mail may be easier to forge than handwritten or signed papers.
Copies of e-mail may exist even after the sender or the receiver has deleted his or her copy.
E-mail service providers have a right to archive and inspect e-mails.
E-mail may be intercepted, altered, or used without detection or authorization.
E-mail may spread computer viruses.
E-mail delivery is not guaranteed.

Conditions for the use of e-mail

Patients should not use e-mail for medical emergencies or to send time-sensitive information to providers. Patients should understand and agree that it is their responsibility to follow up with UW Medicine providers or staff if they have not received a response to an e-mail within a reasonable time period. Patients who send e-mail messages should state a question or concern briefly and clearly, and include:

A subject line that describes the question or concern, and
clear patient identification, including patient name, telephone number and patient identification number in the body of the message.

Patients should inform UW Medicine Registration of any changes to an e-mail address. In addition, if a patient decides to withdraw consent to use e-mail communications about healthcare, the patient should inform providers or a UW staff member in writing.

* I have read and understand the above, "Risks of Using Email."