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Request an Appointment

Request an Appointment

Use this form to request a future appointment with a Mankato Clinic healthcare provider. A scheduler will contact you within two business days to complete the scheduling process with you and book your appointment.

"*" indicates required fields

Hidden

Date Submitted

MM slash DD slash YYYY

Patient Information

Is this for a new patient to the Mankato Clinic?*

Yes

No

Patient Name*

First Middle Last

Patient Date of Birth*

This information helps us locate or establish patient records.

Month

Day

Year

Patient Sex*

This selection helps us locate or establish patient records.

Male

Female

Other

Prefer Not to Answer

Patient Address*

Street Address Address Line 2 City State ZIP Code

Who is completing this request form?*

Understanding the relationship between the patient and the person filling out this request form will help us follow up within privacy requirements.

Patient (for myself)

Parent / Guardian (for my child or dependent)

Other

Contact Information

We respond to appointment requests Monday-Friday between 7am and 5pm. Please provide contact information where we can follow up with you during this period to finish scheduling your appointment.

Primary Phone Number*

Alternate Phone Number

Email Address

Appointment Details

Please let us know more about the type of appointment you are looking for.

I would like to schedule for*

a Speciality

a Location

a specific Mankato Clinic provider

an Annual Preventive Visit

Speciality*

Please select the specialty department you'd like to schedule with

Location*

Please select the location you'd like for this appointment

Provider*

Please select the provider you would like to schedule with.

Reason for Requesting an Appointment*

Please provide some general information about what you'd like to address with the provider in this appointment.

Perferred Appointment Day(s)

Please indicate your preferred scheduling day. (Please check all that apply)

No Preference

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Time of Day

Please indicate which times of day work best for you for your scheduling needs. (Please check all that apply)

No Preference

Early Morning

Late Morning

Early Afternoon

Late Afternoon

Phone

This field is for validation purposes and should be left unchanged.

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Mankato Clinic Foundation

1230 East Main Street
Mankato, MN 56001

Mankato Clinic

24-Hour RN Healthline: 1-877-222-7530

Call 1-507-625-1811

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