Appointment Request - International

After you've sent this request, we will call you within one to two business days to help you make an appointment.

You can also make an appointment by calling (888) 352-7874.

Web Form Detail:      

Patient Information

First Name

Middle Initial

Last Name

Date of Birth








Zip Code

Contact Information

Name (if different than the patient's name)

Phone Number


Alternate Phone

Email Address


Best Time to Contact

Appointment Information

Has the patient seen a RUSH provider before?:

Do you know which provider you would like to see?

Provider Specialty:

Other Insurance:

Preferred date or time for an appointment

Reason for Appointment:

What days and times are generally best for you?:

Would you like us to look for providers near a specific location, such as your home or workplace? If so, please list the address.

How did you hear about us?: