Upstate University Hospital
Request an Appointment/Referral

For more information about a department or a physician, please fill out the form below, or call 315 464-8668 or 800 464-8668 (within NYS only) to speak with an Upstate Connect nurse. Unfortunately we can't make appointments on-line through this website, but we will gladly assist in directing you to the proper phone number. Thank you.

Please do not use this form to send Consult Requests or personal emails to physicians. Consult Requests and personal emails will not be forwarded to physicians.

Fields with * are Required

Patient Information

The person who will be seeing the physician.

*Has the patient been seen at Upstate before? Yes No

*First Name:

Middle Initial:

*Last Name:

*Date of Birth: (mm/dd/yyyy)

*Phone Number: (000-000-0000)

Email Address: (someone@somewhere)

Street Address:

City:

State:

Zip Code:

*Insurance Plan: (If no insurance, please enter "NONE")

Requester Information

The person completing this form.

*I am submitting this request for my (If Self, the following can be skipped)

First Name:

Last Name:

Phone Number: (000-000-0000)

Email Address: (someone@somewhere)

Doctor Information

*Refer To: Gregory W Fink, MD, Surgery

*Referring Physician Name: (Full Name, if none, please enter "NONE")

Additional Information

*Message/Comments:

This question is to prevent automated spam submissions.
Math question: * 7 + 6 =
Solve this simple math problem and select the answer.
E.g. for 1 + 3, select 4.

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Upstate University Hospital Request an Appointment/Referral

Upstate University Hospital
Request an Appointment/Referral