Name: | DOB: | MRN: | PCP:

Appointment Request

If you would like to request an appointment but do not have a MyChart account, you may use the form below. If you already have a MyChart account, please log in instead of using this form.

If you need help requesting this appointment, please call the clinic instead at 715-847-2121.

Please allow two business days for a response to your request. Asterisk (*) denotes required field.

Appointment Request

Since it may take up to 2 days for a response, please only request an appointment at least 2 days in the future.

Preferred Times: