Appointment Request Form

  • Thank you for choosing Urology Associates, LLC for your urology care needs. Use this form to request an appointment. If you have any questions or need assistance filling out the forms, please call our new patient coordinator at (765) 289-7444.
  • List below all current medications you are taking. (Please specify if you have any prescriptions that need to be refilled within the next 30 days)
  • Medication
  • Refill within 30 days?
  • Medication
  • Refill within 30 days?
  • Medication
  • Refill within 30 days?
  • Medication
  • Refill within 30 days?
  • Medication
  • Refill within 30 days?
  • Medication
  • Refill within 30 days?
  • Samuel C. Kim, MD | Robert S. Williams, MD | Jeffery C. Ulrich, MD | Albert N. Bruno, MD Onisuru T. Okotie, MD | David W. Hall II, MD | Trent A. Rees, PA-C