Request an Appointment with The Ear Institute

By taking a few minutes to complete this form, you -- or your representative acting on your behalf -- can request an appointment with the Ear Institute at New York Eye and Ear Infirmary of Mount Sinai. Once your form is submitted, you should expect a response from our 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.

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If you would prefer to make an appointment by phone, please call the Ear Institute directly at (212) 614-8379.

The Ear Institute 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   


*State or Province   

*ZIP or Postal Code   


Call me at this number first 

Other Telephone  

Call me at this number first 

Best time to call   

Email Address 

*Patient's Date of Birth  


*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 (if you have it)

Reason for Visit   

Medical Record #   

7 digits, no spaces or dashes

Contact Information

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

Relationship to Patient   


 First Name   

Middle Initial   

Last Name   



State or Province   

ZIP or Postal Code   


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
I've been a patient at NYEE before
Other (please specify)

Contact Us

The Ear Institute
New York Eye and Ear Infirmary of Mount Sinai
380 Second Avenue, 9th Floor
(between 21st-22nd Streets)
New York, NY  10010
(212) 614-8379 Main Number
(646) 438-7809 FAX



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