UAB Sports & Exercise Medicine Online Appointment Request
Patient Demographics
Legal First Name
Legal Last Name
Date of Birth
Phone Number
Email
If the patient is under the age of sixteen (16), please provide the Guardian Legal Name
Guardian First Name
Guardian Last Name
Do you live in the state of Alabama?
Yes
No
Have you been a patient of UAB before?
Yes
No
Are you or your child affiliated with a school, club or sports team? If so, please list.
Reason for Appointment Request
Laterality
Left
Right
Bilateral
N/A
Body Part
Head
Neck
Shoulder
Elbow
Wrist/Hand
Back
Hip/Pelvis
Thigh
Knee
Lower Leg
Foot/Ankle
Briefly describe your injury or condition
Have you had imaging (X-Ray, MRI, CT) on this body part in the last 6 months?
Yes
No
Is there anything else you would like us to know about your injury or condition?
Are you requesting a referral to schedule with Outpatient Physical Therapy ONLY?
Yes
No
Preferences
Do you have a location preference for your appointment?
No preference
UAB Hospital–Highlands
UAB Medicine Gardendale Primary & Specialty Care
UAB Medicine Leeds
UAB Medicine Hoover Primary & Specialty Care
UAB Medicine St. Vincent’s One Nineteen
Contact Information