The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

pMBxAmajieAZLmxoKsbA8fb74qTtpC9248vKHrTDGHvKKGcChwve5KkrivpoaSJ97KD9rmVyDnRms28PgGRhIq5MGufeGvZENVCDeKg2yd9EyZN

Please complete the form below to request an appointment with an SIU Medicine provider. Your request will be sent to the appropriate clinic for scheduling and follow up.

Would you like an appointment for a flu shot?

Yes

reset

Would you like to request a virtual visit?

Yes

I'm not sure, tell me more

reset

Who is this appointment for?

Someone else

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Which location will you be visiting?

With which department will the appointment be?

What is your name?

Relationship to patient

Phone number

Email address

Legal first name

Legal middle name

Legal last name

Street address

City

State

Zip code

Primary phone number

Email address

Would you like to receive updates about SIU Medicine?

Yes

reset

Patient's Birthday

M-D-Y

Does the patient have health insurance?

Yes

Yes, but I choose NOT to use my insurance

I'm not sure

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Name of insurance provider

Address of insurance provider

Expand

Insurance ID number

Insurance group number

Gender

Male

Female

Prefer not to say

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Brief reason for appointment

Would you like to request a specific provider?

Yes

reset

Name of preferred provider

timestamp

M-D-Y

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Appointment Details

Patient Information

Insurance Information

(Information is required for new patients)

Optional Information

You have selected an option that triggers this survey to end right now.