Request an Appointment

Please fill out the form below and click on the submit button at the bottom of the page to send. A representative will then contact you with appointment options within two business days.

Please note: This form is not intended for urgent appointments or for appointments that you may need within three business days.
If this is a medical emergency, immediately call 911 or go to the nearest emergency room.

  • Urgent Appointments: If you wish to request an appointment within the next three days, call 706-721-CARE (2273) or 800-736-CARE (2273).
  • Dental Appointments: To request an appointment for dentistry, please call 706-721-2371 between 8 a.m. - 5 p.m. EST, Monday-Friday.
  • Privacy and Security: This online appointment request is secure (SSL technology) and information submitted will not be shared with persons outside the appointment-making process.
* Required
Designation
Last Name: *   First Name: *  
Birth Date *   Age *  
Sex: Social Security Number (Last Four Digits Only)

Street Address:
City: State: Zip Code:

Do you prefer to be contacted by:
Phone #: *  
Evening Phone: E-mail:
Primary Care Physician & Phone:

Insurance:
Insurance Company Policy Number Group Number

Reason For Appointment:
Requested Physician Clinic

Which days/times do you prefer for your appointment:







Note: Times are independent of days.

How did you hear
about us?






Medical Center at Augusta University is now accepting online appointment requests for most departments excluding dentistry. Many specialists require a physician's referral before they accept an appointment. Please know that you may need to obtain this referral before we can schedule an appointment.
Additional Comments:
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Your information will take a moment to process. To avoid duplicate submission, please do not click on the back button or hit submit more than once.