Request an Appointment
Use this form for non-urgent appointments only
Today's Date
Patient's First Name:
Patient's Last Name:
Patient's Date of Birth:
Name of person to contact if different than patient:
Phone Number:
Best time to contact me:
Preferred Location:
Patient is a:
Name of provider or speciality you wish to see (optional):
Preferred Appointment Date and Time: 
Please provide a brief reason for the appointment (i.e.: Physical, Medication check, Headache, etc)
A scheduler will call you at the phone number provided above during our normal clinic hours to arrange an exact appointment date and time.
(Please call us at (763) 587-7900 for general information)
Appointment Scheduled: