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Fairview Appointment Request Form

 
If you are experiencing a medical emergency, call 911 or go to the closest Emergency Department. Online appointment requests are not monitored continuously. We will respond to your request within 24 hours on normal business days.

Please call your clinic directly if you wish to reach or leave a message for your doctor.


* Required Field
Although all fields are not required the more information provided at this time the less you may need to provide by phone or at your clinic. Thank you. 

Appointment Information  
*Please choose specialty.
    
 
Preferred Day of Week
Preferred Appointment Time
Preferred Date   
Preferred Date (second choice)   
Clinic Location
Provider
Provider 2nd Choice
Any available provider
Patient Information  
Have you ever been seen at a Fairview Hospital or Clinic? *
 Yes  No
What is your gender? *
 Female  Male
Last Name *
First Name *
Middle Initial
Birthdate *(mm/dd/yyyy)
Address Line 1
Address Line 2
City
State
Zip
Contact Information  
Please enter the contact information to schedule the appointment.
Contact Person *
Relationship to Patient*
Day Phone (include area code) *
Email Address *
Confirm Email Address *
Preferred Follow-up Method*
Insurance Information  
Self Pay or Insurance Name *
Insurance ID
Insurance Group Number
Insurance Subscriber (the person who carries this insurance)
Subscriber's Birthdate (mm/dd/yyyy)
Subscribers place of Employment
Date insurance started, if known
Amount of co-pay, if applicable
 
The information contained on these web pages are intended to provide helpful health information for you. It is made available with the understanding that Fairview Health Services is not engaged in rendering medical, health, psychological, or any other kind of personal professional services on this site. The information should not be considered complete and does not cover all diseases, ailments, physical conditions or their treatment. It should not be used in place of a call or visit to a medical, health or other competent professional, who should be consulted before adopting any of the suggestions in this site or drawing inferences from it. Regardless of what the web pages states, if you think you may have a medical emergency, call your doctor or 911 immediately. You assume all responsibility and risk for the use of and reliance on the web pages. Fairview Health Services specifically disclaims all responsibility for any liability, loss or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the material on this site.