International Patient Appointment Requests

Please do not schedule travel or come to UAMS until an appointment is confirmed by the International Patient Services Department.

The mission of International Patient Services is to facilitate a prompt appointment process without delays and arrange assistance based on the patient’s specific needs.

All email correspondence and phone contacts are answered in English. If you prefer to speak with a person using your native language, please indicate the desire to have translation assistance below.

Please fill in all fields below with as much detail as possible. We will call or email you if we have any questions.

New International Patient Appointment Request

Name * Required
First Middle Last
Date of Birth * Required
MM slash DD slash YYYY
Gender * Required
Phone Number * Required

Please include the country code and/or area code where applicable.
Alternate Phone Number

Please include the country code and/or area code where applicable.
Email Address * Required
Address * Required
Street Address Address Line 2
City * Required
City
State / Province / Region
State / Province / Region
Zip / Postal Code * Required
ZIP / Postal Code
Country * Required
Country
Patient's Diagnosis * Required
Date of Diagnosis Prior to Treatment * Required
MM slash DD slash YYYY
Primary Language * Required
Secondary Language
Interpreter Services Needed? * Required
Your Information
If you are submitting this form on behalf of another person, please fill out the section below.
Name * Required
First Middle Last
Relation to Patient * Required
Phone * Required
Please include the country code and/or area code where applicable.
Phone
Please include the country code and/or area code where applicable.
Email Address
What is the best time for us to call? * Required

Please include the time zone.
Preferred Method of Payment
Does Patient require wheelchair assistance at Little Rock Airport or UAMS? * Required
- Yes
- No
Additional Comments or Questions?

New International Patient Appointment Request

Your Information