Schedule an Appointment

Please provide the information below so that we can schedule an appointment with a certified application counselor at one of our UNC Health Care hospitals.

First Name

Last Name

Home Address

Home Phone Number

Cell Phone Number

Email Address

Hospital you live or work closest to

UNC Hospital Rex Hospital Chatham Hospital Highpoint Regional Hospital Caldwell Hospital Pardee Hospital

Seeking insurance for

Family Individual

Currently Insured

Yes No

What language do you speak?

Please explain any other special needs