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
* Preferred Follow-up Method
Email Address
Email Address Confirm
PHONE: 1st Choice
 —   — 
2nd Choice
 —   — 
3rd Choice
 —   — 
* Relationship
* Diagnosis or Appointment Reason
Optional Information
 
Preferred Appointment Day/Time:
Preferred Clinic or Location:


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