University of Minnesota Physicians Appointment Request
For life threatening emergencies, please call 911. Do not fill out a request.
Your appointment will be scheduled after we contact you to confirm your needs.   We will follow up with you via telephone, Monday-Friday, 8 a.m. 4:30 p.m.  To request an appointment over the phone, please call: 612-672-7422.
Required Information
 
Request appointment for: 
*  First Name  
*  Last Name  
*  Date of Birth  
  
*  Street Address    
*  City/State/Zip        
 
Who should we contact? 
    Check if same as patient name
 
*  First Name *  Last Name
Phone: 
First Choice  
 -  -  
Second Choice  
 -  -  
Third Choice  
 -  -  
*  Relationship  
*  Diagnosis or   
Appointment Reason:  
Optional Information
 
Preferred Appointment Day / Time:  
Preferred Clinic or Location:  


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