Request an Appointment

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

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.

The information you enter is secure. 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

Patient Last Name A value is required.

Patient First Name A value is required.

Reason for Visit

Patient Date of Birth A value is required.Invalid format.
mm/dd/yyyy

Patient Social Security Number Invalid format.
ex. 555-33-8888

Daytime Phone Number A value is required.

Home Phone Number

E-mail Address A value is required.Invalid format.

Preferred Provider

Preferred Clinic

Preferred Day of Week

Preferred Time of Visit Any Time Early Morning (8:30 - 10:00AM) Late Morning (10:00 - 11:30AM) Afternoon Monday Evening (Staples Clinic Only)

How Soon Would You Like Your Appointment

Additional Comments

CONTACT

Request an Appointment