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Fairview Appointment Request Form

For life threatening emergencies, please call 911. Do not fill out a request.

Enter your information below, a Fairview team member will contact you within 24 hours.  You can also set appointments any time of day via MyChart or by calling 1-855-324-7843.

Request Process
Reason for Visit


Is there anything else you would like us to know about your visit? (optional)
Preferred doctor/provider
Any Available Provider
Preferred clinic
(optional)
Preferred appointment day/time (optional)

All information transmitted through this form is secure and will be used only for the stated purpose of contacting the individual to arrange a medical visit.