Minneapolis Health Clinic After Hours Appointment Request Form

Telemedicine Appointment Request Form

Let us know how we can help you!
We are covering Minnesota, Wisconsin, Kansas, Iowa, and Illinois
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select applicable need

USCIS Citizenship Exam Disability Exemption Consultation ( Medical Records Needed)Focussed Primary Care ConsultationImmigration Medical ExamWeight Loss ConsultationMedical Consultation or Service in your home or office (wellness hydration, weight loss, physical therapy, etc)Semaglutide Weight Loss Program (Semaglutide injection every week)Semaglutide 25% off holiday special-$199.Tirzepatide 25% off holiday special -$299Mental Health Consultations (States covered: Minnesota and Arizona)ADHD Assessments (States covered: Minnesota and Arizona)
Note: We accept CareCredit, HSA and medical insurance as a payment option and we cover multiple states. Please note that not all services are covered by medical insurance.
Upload your insurance card or relevant medical information

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Telemedicine Appointment Request Form