Fairview and HealthEast Appointment Request Form

For life threatening emergencies, please call 911. Do not fill out a request. Submissions to this form are not monitored 24 hours a day.

For new patients that need assistance scheduling an appointment, complete the form below and a representative will contact you within 1 day or call 1-855-324-7843 anytime. Current patients may schedule online using MyChart.

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 (required)


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.