Please complete the form below to request an appointment. We will confirm your request within one business day. For prescription refills, please call your provider's office.If you are experiencing a medical emergency, call 911 immediately. Question Title * Would you like to request an appointment with a health care provider? Yes No Question Title * Contact Information Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * Date of Birth Enter Date Date Question Title * Gender Male Female Question Title * Have you been seen by a Utica Park Clinic provider within the last two years? Yes No Question Title * Service Requested Bariatric Surgery Breast Care/Surgery Cancer Care Colorectal Surgery Dermatology Ear, Nose & Throat Endocrinology Family Medicine Gastroenterology Hematology Internal Medicine Medical Oncology Neurology Obstetrics/Gynecology Oncology Orthopedic Care Pain Management Palliative Care Pediatrics Physical Rehabilitation Plastic Surgery Pulmonology/Critical Care Social Services Sports Medicine Surgery Urology Wound Care Question Title * Preferred Clinic Location Bixby Bristow Broken Arrow North Broken Arrow South Catoosa Claremore Cushing Glenpool Henryetta Jenks Okemah Okmulgee Owasso Pryor Sand Springs Sapulpa Tulsa - 12th & Utica Area Tulsa - 21st & Harvard Tulsa - 31st & Garnett Tulsa - 44th & Harvard Tulsa - 71st & Hwy 75 Tulsa - 76th & Lewis Tulsa - 81st & Memorial Tulsa - 91st & Hwy 169 Tulsa - 9245 S. Mingo Tulsa - 101st & Sheridan Tulsa - Pine & Lewis Question Title * Appointment Date Requested Select Date Date Question Title * Message|Additional Comments Submit