971 2 599 9555
800 555 555 (Toll Free)


Please fill out the below form if you wish to book an appointment at Universal Hospital. We will get in touch with you as soon as possible. Once we receive your details, we will contact you directly regarding the available appointments.

Your Personal Details

  • First Name*
  • Middle Initial
  • Last Name*


  • Do you have a current referral from your Doctor?  Yes No
  • Do you have current x-rays (within last 3 months)?  Yes No

Contact Details

  • Home Number*
  • Mobile Number*
  • Business
  • Email Address*
  • Preferred Contact Method:  Email Phone
  • Preferred Location

  • Select Doctor

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