M Health Appointment Request


For life threatening emergencies, please call 911. Do not fill out a request.
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.

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 to Patient (Self, Parent, Referring Physician, etc.)
* Diagnosis or Appointment Reason
Optional Information
 
Preferred Appointment Day/Time:
Preferred Clinic or Location:




End of Form


A collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.