Make an Appointment

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

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 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
  • 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:

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