Hackensack University Medical Center's
OnLine Scheduling

If you would like to request an appointment via our online scheduling service please use this form. All red fields are mandatory and must be completed in order for your request to be submitted. Hackensack University Medical Center (HUMC) Scheduling Coordinators receive all internet inquiries and place return phone calls between
8:30 a.m. and 4:30 p.m., Monday through Friday. HUMC considers the information you provide confidential and we do not share it with any third parties.

You will receive an e-mail confirmation that HUMC received your request and is processing it.

Please note: some tests may require a physician's prescription. For these, you need to bring the prescription with you on the day of your appointment. Please contact your doctor directly if you have any questions about the prescription(s) for your test(s). Some procedures require pre-authorization from your health insurance carrier. Please check with your insurance provider.

If you have any questions about this form, or prefer to make an appointment by telephone, please call:
For Pre Admission Testing (PAT): 201-996-2099
For Outpatient Breast Center or Heart Center: 1-866-411-HUMC

Thank you for choosing Hackensack University Medical Center and we look forward to providing you with the highest quality healthcare.

Please provide the following contact information:

Appointment Type
Procedure Date
First Name
Last Name
Middle Initial
Street Address
City
State
Zip
Sex
Male Female
Home Phone
Best Time of the Day to be Reached
a.m. p.m.
Work Phone
Best Time of the Day to be Reached
a.m. p.m.
Cell Phone
Best Time of the Day to be Reached
a.m. p.m.
E-mail
Date of Birth
Health Insurance Carrier
Policy Number
Physician's Name
Physician's Phone
Preferred Day of the Week
Preferred Time of the Day
a.m. p.m.