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Home Clinics New Patient Appt. Request
Request an Appointment for a New Clinic Patient

 

New Clinic Patient Appointment Request

  1. Welcome to HealthEast clinics! To register as a new patient and then request an appointment, use the form below. A scheduler will call you during business hours to schedule your appointment. We will attempt to contact you three times via phone within 24 hours, and then, if unable to reach you, we will send you an e-mail.

    If you have questions or would like to schedule your new patient appointment by phone, call 651-326-1660.

    We encourage current patients to use our patient portal to request appointments online. Our portal allows you to request and cancel appointments online, send messages to and receive messages from your doctor and create an online personal health record.

    This service is for non-urgent appointment requests. If this is an urgent medical problem, call your doctor's office or 911.

    *Required Fields

  2. Requestor information

  3. First name*
    Enter the requestor's first name.
  4. Last name*
    Enter the requestor's last name.
  5. E-mail address*
    Please enter a valid e-mail address

  7. Patient information

  8. *


    Select if the patient is the same or different as the requestor.
  9. First name*
    Enter the patient's first name.
  10. Last name*
    Enter the patient's last name.
  11. Patient date of birth*
    Enter a valid date of birth.
    mm/dd/yyyy
  12. Is patient a minor?*
    Is patient a minor?
  13. Sex*
    Indicate patient's sex.
  14. Address*
    Enter your street address.
  15. City*
    Enter your city.
  16. State*
    Select your state.
  17. Zip code*
    Enter your zip code.

  19. Health Insurance
    Invalid Input
  20. Policy number
    Invalid Input
  21. Policy subscriber
    Invalid Input

  23. Phone number(s)
  24. Preferred*
    Enter a valid phone number.
    xxx-xxx-xxxx
  25. Alternate
    Invalid Input
    xxx-xxx-xxxx
  26. Best time to call:*




    Indicate the best time for us to call.
  27. May we leave a message?*
    Please indicate if we can leave a message.

  29. Guarantor information

    (person responsible for the bill)
  30. Guarantor name *
    Enter the name of the person
    responsible for the bill.
  31. Address *
    Enter the guarantor's address.
  32. City *
    Enter the guarantor's city.
  33. State *
    Select the guarantor's state.
  34. Zip code *
    Enter the guarantor's zip code.
  35. Phone number *
    Enter the guarantor's phone number.
    xxx-xxx-xxxx

  37. Appointment information

  38. Type of appointment*



    Indicate type of appointment.
  39. Preferred clinic*
    Select a clinic.
  40. Preferred day(s)*






    Select your preferred day(s).
  41. Preferred time*
    Select your preferred appointment time.

  43. Additional information

  44. We review all patients' treatment to ensure that everyone receives the highest quality of care. To help with our review, can you please provide your race, country of origin and religion.


  45. What race best describes you?
    Invalid Input
  46. In what country were you born?
    Invalid Input
  47. What religion do you practice?
    Invalid Input
  48. Preferred language
    Indicate your preferred language.
  49. How did you hear about HealthEast?
    Tell us how you first learned about HealthEast.

  51.   

 
 
 
 
 
 
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