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Request An Appointment

Please complete the form below to request an appointment at Midsota.

The information you enter is secure. We will contact you by phone or e-mail within two business days to confirm your requested appointment time.

Please do not use this form in case of an emergency. In an emergency, please call 911.

This form will take less than 5 minutes to complete.
An Asterisk (*) indicates a required field.
 
*Patient First Name
*Patient Last Name
*Type of Visit
*Reason for Visit
If your type of visit is not listed, you will need to call 320-253-7257 to schedule your appointment.
Location to be seen
*Has Patient Been Here Before
*Patient Birthdate
*Patient Address
*City
State
*Zip
*Your First Name
*Your Last Name
*Your Relationship to Patient
*Day-time Phone Number
Home Phone Number (If Different)
*Best Time to Reach You by Phone
*Email Address
Please be sure you have entered your e-mail address correctly or we will be unable to contact you.
*How would you like us to contact you with your appointment time?
If we have any questions about your request, we will contact you by phone at the daytime phone number you entered above.
*Does the Patient Have Health Insurance
 
If yes, please complete the following items:
Health Insurance Plan
Insurance Company Name
Insurance Plan Number
Insurance Group Number
You may need a referral from your Primary Care Clinic
 
*Specific Provider You Wish to See
*Day of the Week (Select all that apply):
 Note: Not all providers are available on all days Any Day
Monday
Tuesday
Wednesday
Thursday
Friday
*Time of Day (Select all that apply): Note: Not all providers are available at all times Any Time
Early Morning (8:00AM~10:00AM)
Late Morning (10:00AM~11:30AM)
Early Afternoon (1:30PM~3:00PM)
Late Afternoon (3:00PM~4:30PM)
*How soon would you like the appointment
*How did you find out about our online appointment request process?
Additional Information or Comments (Briefly describe symptoms and list routine medications taken):
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