URMC / Dizziness Clinic / Dizziness Appointment Form Dizziness Appointment Form Contact Information First Name: Last Name: Phone Number: ( ) - Second three digits Last four digits Email Address: Zip Code: Additional Information Preferred Appointment Time: MorningAfternoonNo preference Preferred Day of Week: WednesdayThursdayNo preference Would you like to receive occasional emails from the Dizziness Clinic?: YesNo Questions or Comments: Our Privacy Policy