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Notice--The use of online appointment scheduling is not for emergencies. It is to be used only for regular appointments. If this is an emergency please call 911 or call one of our offices for further assistance. Thank You, Southeast Urologists.


Appointment Scheduling

First Name:  MI:
Last Name:
Age:
Sex:

Email:
Please be sure to submit your complete email address
(ex. jane@aol.com)

Phone: - -
In order to recieve information on your healthcare
topic from Southeast Urology, please include
the following information:
Mailing Address:
Mailing Address:
City: State: Zip:
Have you previously sought care for this medical issue
from any Physician/Hospital?
Yes No
Health Insurance Plan:
Is there a specific physician you would like to see?
If yes, which one?
Do you have a preference for a specific physician's
specialty? If yes, specify:

In the window below, please describe your medical
issue. It would be helpful to include those details
that you are comfortable sharing if appropriate, a
diagnosis, symptoms, and what you want to achieve
(ie specialty consultation, procedure, options for
referral, information on sponsor facilities, etc).

Note: The information you submit on this page will
not be seen immediately by Southeast Urologists.
When you click "Submit" the information will be
delivered to the SUN.
DO NOT USE THIS PAGE FOR URGENT OR EMERGENT
 MEDICAL SERVICES.

What is your Medical Issue?

Can contain up to 255 characters
Appointment preference: (Please choose the day and
time of the day you prefer.)We will make every effort to
accommodate your preference for an appointment.
Appointment availability is also contingent on physician
availability.

Use the Control key to select more than one item
* Macintosh users, hold the apple key

Days of the Week: Time of Day: An appointment within:
Best time for a representative to call you if further
information is needed to schedule an appointment.


 
East Office
995 S. Yates
Suite 1
Memphis TN 38119
Tel: 901.527.7100
Fax: 901.527.7124
Southaven Office
7420 Guthrie Drive North
Suite 111
Southaven, MS 38671
Tel: 662.349.2220
Fax: 662.349.4414