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Last Updated:
5/23/2020
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Below is a sample of the emails you can expect to receive when signed up to n M.

? Thank you for contacting Northwestern Medicine's Physician Referral Service. A Referral Specialist will respond to your request within 2 business days Monday-Friday; 8am-5pm CST.

Please do not respond to this e-mail confirmation. If you require immediate assistance please call the Physician Referral Service at 1-844-344-6663; one of our Referral Specialists would be happy to assist you.

You have consented to allow Northwestern Memorial HealthCare (NMHC) to disclose confidential health information, which you provided to NMHC through its physician web site, to an affiliated physician office. This consent is effective as of the date you make the request for the service and shall expire on the date after NMHC has provided the information to the affiliated physician.

The confidential health information provided by you in requesting an appointment shall be utilized only for the purpose of helping you secure an office visit with an affiliated physician or to schedule a diagnostic or therapeutic test with NMHC.

You can revoke this authorization at any time by notifying NMH in writing at the following address:

Manager, Physician Referral Services
541 N. Fairbanks Ct, Suite 1300
Chicago, IL 60611
Fax: 312/926-0028
e-mail: PhysicianReferral@nm.org

Thank you.

This message and any included attachments are intended only for the addressee. The information contained in this message is confidential and may constitute proprietary or non-public information under international, federal, or state laws. Unauthorized forwarding, printing, copying, distribution, or use of such information is strictly prohibited and may be unlawful. If you are not the addressee, please promptly delete this message and notify the sender of the delivery error by e-mail.

Raw DataRegistration StructureRegistration Form Text
Registration
Date of Birth
First name
Last name
Email
Phone
Home address
City
State
County
Zipcode
Gender
Select
Select
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virg
Yes
Select
Select
Select Self Spouse Parent Other Back Next Appointment Preferences What t
Adult
Select
Select
Select
Select
Select No Preference 9 AM - 11 AM 11 AM - 1 PM 1 PM - 3 PM How would you like to receive your appointment information?
Email
Data Name Data Type Options
Date of Birth   Text Box
First name   Text Box
Last name   Text Box
Email   Text Box
Phone   Text Box
Home address   Text Box
City   Text Box
State   Text Box
County   Text Box
Zipcode   Text Box
Gender   Text Box
  dropdown Select
  dropdown Select
  option Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virg
  option Yes
  dropdown Select
  dropdown Select
  option Select Self Spouse Parent Other Back Next Appointment Preferences What t
  option Adult
  dropdown Select
  dropdown Select
  dropdown Select
  dropdown Select
  option Select No Preference 9 AM - 11 AM 11 AM - 1 PM 1 PM - 3 PM How would you like to receive your appointment information?
  option Email

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