UIC Phone Intake Form Please fill out the requested inputs Patient's Name* First Last Patient's Cell Phone*Patient's Email Address* Purpose of Appointment*Are You Currently in Pain or Discomfort?* Yes No If Yes, Where? UL UR LL LR Day of the Week Requested* Monday Tuesday Wednesday Thursday Friday Any Time of the Day Requested* Morning Afternoon Any Location Requested* Indianapolis Fishers Any Script for UIC to end the call: If call answered BEFORE 4pm Monday through Friday: “Thank you for providing this information, one of our NEW PATIENT CARE COORDINATORS will return your call as soon as they finish taking care of the patient they’re currently with. They will be calling you back at repeat phone number provided by patient” If called answered AFTER 5pm Monday through Friday or on the weekends: “Thank you for providing this information, one of our NEW PATIENT CARE COORDINATORS will return your call as soon as possible as our offices are currently closed. They will be calling you back at repeat phone number provided by patient” 46257
