New York Eye and Ear Infirmary
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How to Use this Form

This form is for EYE or ENT General Care Center Appointments ONLY

By taking a few minutes to complete this form, you -- or your representative acting on your behalf -- can request an appointment with the EYE or ENT General Care Center at The New York Eye and Ear Infirmary of Mount Sinai. Once your form is submitted, you should expect a response from our Appointment Desk staff within 48 hours (Monday through Friday.).

This form is not for emergency services. For emergency medical treatment or medical advice concerning specific conditions or treatments, please consult with a qualified health care provider or go to your nearest Hospital Emergency Room.

About Privacy

For your privacy, this form uses SSL technology to ensure that the information you are submitting is secure.    Please view our website privacy policy >>

If you would prefer to make an appointment by phone, please call the Appointment Desk at (212) 979-4192. 

 
Appointment Request Form

Patient Information * indicates a required field

* Title   

* Patient's First Name   

Patient's Middle Initial   

* Patient's Last Name   

* Patient's Address   

* City   

* State or Province   

* ZIP or Postal Code   

* Telephone  

Call me at this number first 

Other Telephone

Call me at this number first 

* Patient's Date of Birth  

dd/mm/yyyy

* Patient's Sex  

Male Female

* Have you been a    
patient at NYEE before?
  

Yes No
If you answer YES, please provide your Medical Record Number below

Medical Record #   
if you have been a    
patient at NYEE    
before, this # will    
be on your red card    

7 digits, no spaces or dashes

Contact Information

Best time to call   

Please provide the following information if different from above. This person will be the primary contact for the appointment request.

Relationship to Patient   

Title   

 First Name   

Middle Initial   

Last Name   

Address   

City   

State or Province   

ZIP or Postal Code   

Telephone   

Call me at this number first

Other Telephone   

Call me at this number first 

Optional Information

How did you find   
our website?   

Infirmary Phone "Hold" Message
Knew web address
Search Engine
Link from another website
Friend/Word of Mouth
Advertisement
I've been a patient at NYEE before
Other (please specify)

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