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.

Our providers continue to see patients during this time, with options for phone, video and in-person visits. Please complete the appointment request form below or call us at 1-855-FAIRVIEW (1-855-7843) and we can help you schedule a visit. If it's possible to see your provider through a video visit, we'll guide you through that process.

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.