M Health 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 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.