Fairview

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Online appointment requests are not monitored continuously. We will respond to your request within 24 hrs on normal business days.</b></td> </tr> <tr> <td align="left" class="logi_3"> <br/><b>* Required Field</b><br/><b>Although all fields are not required the more information provided at this time the less you may need to provide by phone or at your clinic. Thank you.</b>  </td> </tr> </table> </div> </td> </tr> <tr> <td valign="top"> <table border="0" cellpadding="2" cellspacing="1"> <tr>  <td align="center"> <div class="WarningMessage"></div><br/> </td> </tr> <tr> <td valign="middle" align="left"> <div id="header1field_div" style="display:inline"> <table border="0" cellpadding="0" cellspacing="0" width="500"> <tr> <td align="left" class="logi_21"> <b>Appointment Information </b>  </td> </tr> <tr> <td align="left"></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="reason_for_visitfield_div" style="display:inline"> <a name="ReasonInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="600"> <tr> <td valign="middle"> *Please list reason for visit or symptoms for visit (this will help us to allocate enough time for your appointment). </td> </tr> </table> <table cellpadding="2" cellspacing="2" border="0" width="600"> <tr> <td class="logi_26"> <textarea class="" id="reason_for_visit" name="reason_for_visit" cols="59" rows="4"></textarea> </td> </tr> </table> <table cellpadding="2" cellspacing="2" border="0" width="600"> <tr> <td valign="top" class="logi_26"> <b>*You may leave more details here if you need to be more specific on your appointment needs. <br/>*If this is medication recheck please give the names of medications that will be rechecked.</b> </td> </tr> </table> </div> </td> </tr> <tr><td> </td></tr> <tr> <td valign="middle" align="left"> <div id="preferred_dayfield_div" style="display:inline"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Preferred Day of Week </span></td> <td valign="middle" class="logi_global"> <select name="preferred_day" class="" id="preferred_day"> <option value="No Preference">No Preference</option> <option value="Monday">Monday</option> <option value="Tuesday">Tuesday</option> <option value="Wednesday">Wednesday</option> <option value="Thursday">Thursday</option> <option value="Friday">Friday</option></select> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="appointment_timefield_div" style="visibility: inherit; display:inline"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Preferred Appointment Time </span></td> <td valign="middle" class="logi_global"> <select name="appointment_time" class="" id="appointment_time"> <option value="No Preference">No Preference</option> <option value="7am - 9am">7am - 9am</option> <option value="10am - 12pm">10am - 12pm</option> <option value="1pm - 3pm">1pm - 3pm</option> <option value="4pm - close">4pm - close</option></select> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="preferred_appt_datefield_div" style="display:inline"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Preferred Date </span></td> <td valign="middle" class="logi_16"> <input type="button" id="btnDatePicker" name="btnDatePicker" onclick="pickDate(preferred_appt_date)" size="4" value="Choose Date"/>   <input style="border-style: none;font-size: 12" class="" name="preferred_appt_date" value="" id="preferred_appt_date" size="12" maxlength="12"/> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="preferred_appt_date_2ndfield_div" style="display:inline"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Preferred Date (second choice) </span></td> <td valign="middle" class="logi_16"> <input type="button" id="Button1" name="btnDatePicker" onclick="pickDate(preferred_appt_date_2nd)" size="4" value="Choose Date"/>   <input style="border-style: none;font-size: 12" class="" name="preferred_appt_date_2nd" value="" id="preferred_appt_date_2nd" size="12" maxlength="12"/> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="clinic_locationfield_div" style="display:inline"> <table border="0" cellpadding="2" cellspacing="2" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Clinic Location </span></td> <td valign="middle"> <select name="clinic_location" class="" id="clinic_location"> <option value="No Preference">No Preference</option> <option value="Andover">Andover</option> <option value="Bass Lake">Bass Lake</option> <option value="Blaine">Blaine</option> <option value="Brooklyn Park">Brooklyn Park</option> <option value="Cedar Ridge">Cedar Ridge</option> <option value="Children's Clinic">Children's Clinic</option> <option value="Chisago">Chisago</option> <option value="Columbia Heights">Columbia Heights</option> <option value="Crosstown">Crosstown</option> <option value="Eagan">Eagan</option> <option value="Eden Center">Eden Center</option> <option value="Elk River">Elk River</option> <option value="Farmington">Farmington</option> <option value="Fridley 6341">Fridley 6341</option> <option value="Fridley 6401">Fridley 6401</option> <option value="Hiawatha">Hiawatha</option> <option value="Highland Park">Highland Park</option> <option value="Hugo">Hugo</option> <option value="Jonathan">Jonathan</option> <option value="Lakeville">Lakeville</option> <option value="Lino Lakes">Lino Lakes</option> <option value="Maple Grove">Maple Grove</option> <option value="Milaca">Milaca</option> <option value="North Branch">North Branch</option> <option value="NorthEast">NorthEast</option> <option value="Oxboro">Oxboro</option> <option value="Pine City">Pine City</option> <option value="Princeton">Princeton</option> <option value="Ridge Valley">Ridge Valley</option> <option value="Ridges">Ridges</option> <option value="Riverside Women's">Riverside Women's</option> <option value="Rogers">Rogers</option> <option value="Rosemount">Rosemount</option> <option value="Rush City">Rush City</option> <option value="Uptown">Uptown</option> <option value="Wyoming">Wyoming</option> <option value="Zimmerman">Zimmerman</option></select> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="Div3" style="display:inline"> <table border="0" cellpadding="2" cellspacing="2" width="600"> <tr> <td width="250" class="logi_global"> <span id="provider_label1">Provider</span> </td> <td valign="middle"><input type="text" size="35" maxlength="30" id="provider" name="provider" value=""/> </td> </tr> <tr> <td class="logi_global"><span id="provider_label12">Provider 2nd Choice</span></td> <td valign="middle"><input type="text" size="35" maxlength="30" id="provider2nd" name="provider2nd" value=""/> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="Div4" style="display:inline"> <table border="0" cellpadding="2" cellspacing="2" width="500"> <tr> <td width="250" valign="middle"> </td> <td valign="middle" class="logi_global"> <input type="checkbox" name="anyAvailableProvider" id="anyAvaiableProvider"/> Any available provider </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="headerfield_div" style="display:inline"> <table border="0" cellpadding="0" cellspacing="0" width="500"> <tr> <td align="left" class="logi_2"> <b>Patient Information </b>  </td> </tr> <tr> <td align="left"></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="returningPatient_div" style="display:inline"> <a name="returningPatientInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_4"> <b>Have you ever been seen at a Fairview Hospital or Clinic? * </b> </td> <td valign="middle" class="logi_4"> <table> <tr> <td class="logi_4" valign="middle"> <input type="radio" class="" id="returningPatientYes" name="returningPatient" value="Yes"/> Yes </td> <td></td> <td class="logi_4" valign="middle"> <input type="radio" class="" id="returningPatientNo" name="returningPatient" value="No"/> No </td> </tr> </table> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="genderfield_div" style="display:inline"> <a name="genderInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_4"> <b>What is your gender? * </b> </td> <td valign="middle" class="logi_4"> <table> <tr> <td class="logi_4" valign="middle"> <input type="radio" class="" id="genderfemale" name="gender" value="Female"/> Female </td> <td></td> <td class="logi_4" valign="middle"> <input type="radio" class="" id="gendermale" name="gender" value="Male"/> Male </td> </tr> </table> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="last_namefield_div" style="display:inline"> <a name="LastNameInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_5"> <b>Last Name * </b></td> <td valign="middle" class="logi_5"> <input class="" type="text" name="last_name" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="first_namefield_div" style="display:inline"> <a name="FirstNameInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_6"> <b>First Name * </b></td> <td valign="middle" class="logi_6"> <input class="" type="text" name="first_name" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="initialfield_div" style="display:inline"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Middle Initial </span></td> <td valign="middle" class="logi_global"> <input type="text" name="initial" value="" size="5" maxlength="5"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="dobfield_div" style="display:inline"> <a name="DOBInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_16"> <b>Birthdate *(mm/dd/yyyy) </b></td> <td valign="middle" class="logi_16"> <input type="text" class="" name="dob" value="" id="dob" size="12" maxlength="12"/> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="addressfield_div" style="display:inline"> <a name="addressInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Address Line 1 </span></td> <td valign="middle" class="logi_global"> <input class="" type="text" name="address" value="" size="35" maxlength="35"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="address_2field_div" style="display:inline"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Address Line 2 </span></td> <td valign="middle" class="logi_global"> <input type="text" name="address_2" value="" size="35" maxlength="35"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="cityfield_div" style="display:inline"> <a name="cityInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>City </span></td> <td valign="middle" class="logi_global"> <input class="" type="text" name="city" value="" size="20" maxlength="20"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="statesfield_div" style="display:inline"> <a name="statesInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>State </span></td> <td valign="middle" class="logi_global"> <select class="" name="states" class="" id="states"> <option value="Alabama">Alabama</option> <option value="Alaska">Alaska</option> <option value="Arizona">Arizona</option> <option value="Arkansas">Arkansas</option> <option value="California">California</option> <option value="Colorado">Colorado</option> <option value="Connecticut">Connecticut</option> <option value="Delaware">Delaware</option> <option value="District of Columbia">District of Columbia</option> <option value="Florida">Florida</option> <option value="Georgia">Georgia</option> <option value="Hawaii">Hawaii</option> <option value="Idaho">Idaho</option> <option value="Illinois">Illinois</option> <option value="Indiana">Indiana</option> <option value="Iowa">Iowa</option> <option value="Kansas">Kansas</option> <option value="Kentucky">Kentucky</option> <option value="Louisiana">Louisiana</option> <option value="Maine">Maine</option> <option value="Maryland">Maryland</option> <option value="Massachusetts">Massachusetts</option> <option value="Michigan">Michigan</option> <option value="Minnesota" selected>Minnesota</option> <option value="Mississippi">Mississippi</option> <option value="Missouri">Missouri</option> <option value="Montana">Montana</option> <option value="Nebraska">Nebraska</option> <option value="Nevada">Nevada</option> <option value="New Hampshire">New Hampshire</option> <option value="New Jersey">New Jersey</option> <option value="New Mexico">New Mexico</option> <option value="New York">New York</option> <option value="North Carolina">North Carolina</option> <option value="North Dakota">North Dakota</option> <option value="Ohio">Ohio</option> <option value="Oklahoma">Oklahoma</option> <option value="Oregon">Oregon</option> <option value="Pennsylvania">Pennsylvania</option> <option value="Rhode Island">Rhode Island</option> <option value="South Carolina">South Carolina</option> <option value="South Dakota">South Dakota</option> <option value="Tennesse">Tennesse</option> <option value="Texas">Texas</option> <option value="Utah">Utah</option> <option value="Vermont">Vermont</option> <option value="Virginia">Virginia</option> <option value="Washington">Washington</option> <option value="West Virginia">West Virginia</option> <option value="Wisconsin">Wisconsin</option> <option value="Wyoming">Wyoming</option> <option value="Guam">Guam</option> <option value="Puerto Rico">Puerto Rico</option> <option value="US Virgin Islands">US Virgin Islands</option> <option value="Armed Forces Africas">Armed Forces Africas</option> <option value="Armed Forces Americas">Armed Forces Americas</option> <option value="Armed Forces Canada">Armed Forces Canada</option> <option value="Armed Forces Europe">Armed Forces Europe</option> <option value="Armed Forces Middle East">Armed Forces Middle East</option> <option value="Armed Forces Pacific">Armed Forces Pacific</option></select> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="zipfield_div" style="display:inline"> <a name="ZipInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Zip </span></td> <td valign="middle" class="logi_global"> <input class="" type="text" name="zip" value="" size="9" maxlength="9"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="Div2" style="display:inline"> <table border="0" cellpadding="0" cellspacing="0" width="500"> <tr> <td align="left" class="logi_2"> <b>Contact Information </b>  </td> </tr> <tr> <td align="left"></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"><b>Please enter the contact information to schedule the appointment.</b></td> </tr> <tr> <td valign="middle" align="left"> <div id="contactpersonfield_div" style="display:inline"> <a name="ContactPersonInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_19"> <b>Contact Person * </b></td> <td valign="middle" class="logi_19"> <input class="" type="text" name="contactperson" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="relationshipPatient_div" style="display:inline"> <a name="patientRelationshipInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_19"> <b>Relationship to Patient* </b></td> <td valign="middle" class="logi_19"> <input class="" type="text" name="relationshipPatient" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="phonefield_div" style="display:inline"> <a name="PhoneInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_14"> <b>Day Phone (include area code) *</b></td> <td valign="middle" class="logi_14"> <input class="" type="text" name="phone" value="" size="15" maxlength="15"/></td> <td valign="middle" class="logi_global"> <select name="contactmethod" class="" id="contactmethod"> <option value="Home Phone">Home Phone</option> <option value="Mobile Phone">Mobile Phone</option> <option value="Work Phone">Work Phone</option></select></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="emailfield_div" style="display:inline"> <a name="EmailInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_14"> <b>Email Address * </b></td> <td valign="middle" class="logi_14"> <input class="" type="text" name="email" value="" size="30" maxlength="100"/></td> </tr> <tr> <td width="210" valign="middle" class="logi_14"><b>Confirm Email Address *</b></td> <td valign="middle" class="logi_14"> <input class="" type="text" name="emailconfirm" id="emailconfirm" value="" size="30" maxlength="100"/> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="preferredFollowup" style="display:inline"> <a name="preferredFollowup"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_19"> <b>Preferred Follow-up Method* </b></td> <td valign="middle" class="logi_19"> <select class="" name="preferredFollowup"> <option value="Phone">Phone</option> <option value="Email">Email</option> </select> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div style="display:inline"> <table border="0" cellpadding="0" cellspacing="0" width="500"> <tr> <td align="left" class="logi_21"> <b>Insurance Information </b>  </td> </tr> <tr> <td align="left"></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="selffield_div" style="display:inline"> <a name="SelfInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_14"> <b>Self Pay or Insurance Name *</b></td> <td valign="middle" class="logi_14"> <input class="" type="text" name="self" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="insuranceid_div" style="display:inline"> <a name="insuranceidInfo"></a> <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> Insurance ID</td> <td valign="middle" class="logi_global"> <input class="" type="text" name="insuranceid" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="insurancegnfield_div" style="display:inline"> <a name="insurancegnInfo"></a> <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> Insurance Group Number</td> <td valign="middle" class="logi_global"> <input class="" type="text" name="insurancegn" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="insurancesubfield_div" style="display:inline"> <a name="insurancesubInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Insurance Subscriber (the person who carries this insurance) </span></td> <td valign="middle" class="logi_global"> <input class="" type="text" name="insurancesub" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="subDOB" style="display:inline"> <a name="subDOBInfo"></a>  <div class="WarningMessage"></div> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> Subscriber's Birthdate (mm/dd/yyyy)</td> <td valign="middle" class="logi_16"> <input type="text" class="" name="subDOB" value="" size="12" maxlength="12"/> </td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="employer" style="display:inline"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Subscribers place of Employment</span></td> <td valign="middle" class="logi_global"> <input type="text" name="employer" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="insurancedatefield_div" style="display:inline"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Date insurance started, if known </span></td> <td valign="middle" class="logi_global"> <input type="text" name="insurancedate" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td valign="middle" align="left"> <div id="insurancecofield_div" style="display:inline"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td width="250" valign="middle" class="logi_global"> <span>Amount of co-pay, if applicable </span></td> <td valign="middle" class="logi_global"> <input type="text" name="insuranceco" value="" size="30" maxlength="30"/></td> </tr> </table> </div> </td> </tr> <tr> <td align="left"> </td> </tr> <tr> <td align="left"> <table cellpadding="2" cellspacing="2" border="0" width="500"> <tr> <td valign="middle" align="center"> <input type="reset" value="Clear Form" onclick="return confirmReset();"/> </td> <td align="center"> <input type="submit" value="Submit"/>   </td> </tr> </table> </td> </tr> </table> </td> </tr> </table> </center> </form> </td> </tr> </tbody> </table>  </div>   <div class="clear"></div> </div> </div>    <div id="footerContainer" class="footerSwoosh_above png"> <div class="footerNavBox"> <div id="footerNav"> <div id="Footer_Element_1"></div> <div class="clear"> </div> </div> <div id="footerSubNav"> <div id="Footer_Element_2"></div> <div class="clear"> </div> </div> <div id="Footer_Element_3"></div> <div class="clear"> </div> </div> <div class="footerInfo"> <div id="Footer_Element_4"></div> </div> <div class="clear"> </div> <div class="clear"> </div> </div> <script type="text/javascript"> var 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