Make an Appointment

In an emergency, please call 911. Do not use this form if this is an emergency situation! 

New patients or med refillsDo not fill out this form, please call 218-894-1515 for scheduling instead.

Please complete the form below to request an appointment at one of the Lakewood Health System Clinics. We will contact you by e-mail within one business day to confirm your appointment. You will be required to send an e-mail back within 48 hours of receiving your appointment to confirm it. If you do not e-mail us back to confirm your appointment, it will be released and you will have to make a new appointment.
 

Appointment Request
  • If you need to be seen in the next 4 days or if you need to be seen immediately, please call the clinic to make an appointment at 218-894-1515
  • Please provide as much information as possible to help us fill your appointment request.
  • After submitting this request you will be contacted (via e-mail) by our scheduling department to confirm appointment details.
  • E-mail addresses will only be used for the purposes of this appointment request unless you expressly authorize us to use it for additional communications.

Patient Last Name: 
*

Patient First Name:  
*

Patient BirthDate:      
*

Daytime Phone:        

Home Phone:             
*

Email Address:          
*

Reason For Visit:

Preferred Physician:

Preferred Clinic Location:

Preferred Day:

Preferred Time:
 Any Time 
 Early Morning (8:30 am - 10:00 am)
 Late Morning (10:00 am - 11:30 am)
 Afternoon
 Evening (Staples Clinic Only Mon. - Fri.)

How soon would you like to be seen?

Additional Comments:

Staff:    Web sign on | Lakewood staff portal |