- None - Ackerman, Duncan - MD Acharya, Pranab - MD, MPH Altringer, William - MD Anderson, Kathy - MD Anderson, Peter - MD Appert, David - MD Archuleta, Laura - MD Arthurs, Supha - MD Astorne, Walter - MD, FACP Babb-Zachmeier, Amanda - PA-C Baker, Biron D. - MD Bauer, Jody - PA-C Bayer, Tosha - DNP Beachey, Ruth - PT, NCS Becker, Ricky - MD Benson, Jeff - MD Berentson, Lea - PsyD Bharadwaj, Savitha - MD Bock, Laura - PT, DPT Booth, Michael - MD, PhD Bopp, Timothy - MD Borrowman, Theresa - MD Bossart, Allan - PT Botsford, John - MD Brackin, Ilene - PA-C Bradbury, Nicholas - MD Bradley, Shannon - MD Bramati, Patricia - MD Braun, Kristin - FNP-BC Braun, Mandi - PA-C Brooks, David - PhD, ABPP(RP), ABN Brown, Karen - MD Brown, Michael - MD, PhD Bryan, Jennifer - FNP-C Bury, Jan - MD Cannon, Bryan C. - MD Carlson, Chad - MD Carlson, Joseph - MD Chalmers, Aaron - MD Chandler, Kym - MD Charchenko, Cameron - MD Chaussee, Kevin - FNP-BC Christianson, Jane - FNP-C Ciavarella, Tana - PA-C Clauson, Ryan - MD Clement, Jessica - MS, LAPC Connell, Joan - MD Cote, Derrick O. - MD Dahl, Brian P. - MD Dahmen, Kevin - MD Daoud, Ahmed - MD Darras, Kyle - FNP-BC DeGree, Craig - PhD DeKrey, Jeanne - PT, DPT, PRT Delvo, Stephanie - MD Diede, Stan - MD Dietz, Traci - FNP-BC Dixon, Daniel K. - MD Dornacker, Jon - MD Dramko, Joseph - MD Dunnigan, Ralph - MD Earsley, Anne - PA-C Eberle, Sally - FNP-C Ebertz, Mark - MD Eckroth, Janel - FNP-C Ellison, Wesley - MD Erickstad, Faith - FNP Erickstad, John - MD Erickstad, Mark - MD Eshoo, Norman - MD Faiman, Kayla - MS, CCC-SLP Feil, Tara - PhD Fettig, Megan - FNP-BC Finkielman, Javier - MD Fischer, Bernard - RN, FNP-C Folk, Cynthia - FNP Fortney, Aaron - MD Fortney, Mike - MD Francis, Lisa - MD Fredrickson, Ward - MD Fueller, Deb - FNP-C Fuerstenberg, Laura - FNP-BC Gale, Brian - DPM Graeber, LuAnna - PA-C Graf, Stacie - PA-C Gray, Todd - MD Grenz, Donald - MD Grube, Thomas - MD Gustafson, Jean - MD Guthmiller, Tanya - FNP-BC Halsey, Colby - MD Hamar, Matthew - DO Hamar, Steven - MD Harchenko, Vern - MD Harju, Renee - FNP-C Harms Shannon - PT, MPT Hebert, Brian - MD Hefty, Matthew - MD Helbling, Brandon - MD, FACS, FASMBS Herbel, Brent - MD Hetland, Andrew - MD Hilts, George - MD Hilzendeger, Jeff - PA-C Hipp, John - MD Hoffer, Barb - FNP-BC Hofferber, Rick - FNP-C Hollenbeck, Kellee - FNP-C Holmen, John - MD Honeycutt, D'Arcy - MD Horner, Sara - PsyD Hostetter, Jeff - MD Hoyt, John - MD Hutchens, Thomas - MD Hyder, S. Shiraz - MD Ilie, Carmen - MD Iwaasa, Gregory - DPM Jacobs, Sarah - MS, CCC-SLP Jacobus, Karen - AuD Jain, Sunanda - MD Jahner, Cara - FNP-C Jahnke, Joel - PT, DPT, LATC Johnson, Courtney - MS, SLP Johnson, Gary - MD Jondahl, Paul - MD Juelson, Amy - MD Juelson, Timothy J. - MD Kaiser, Trina - FNP Kane, Derek - MD Karls, Kevin - MD Kathawala, Mustafa - MD Kavlie, Gaylord - MD Kenney, Sara - PsyD Kitzman, Annie - FNP-C Kleinjan, Connie - PT Knudsen, Andrew - DPM Koivula, Mark, FNP-C Kozel, Lisa - MD Kraft, Bernie - RD, LRD, CDE Kraljic, Steven - MD Kriengkrairut, Siriwan - MD Lang, Marny - PsyD Larson, Kate - PA-C Laszewski, Linda - MD Laszewski, Michael - MD Leidenix, Monte - MD Lelito, Jamelle - PA-C Levey, Amanda - FNP Levora, Jan - MD Linz, Laurie - MD Litchfield, Douglas - MD Longie, Kelly - MD Longie, Kevin - MD Loraas, Dawn - FNP-BC Luebke, Aaron - MD Lutzwick, Eric - NP-C Lutzwick, Lindsey - NP-C Mahr, Nicholas - MD Malucky, Andrea - FNP-C Marburger, Tessa - MD Markewich, Stephen - MD Martire', Michael - MD Marts, Boyd - MD, PhD Mathew, Boban - MD Mathison, David - MD McKibben, Djaninn - PA-C McPherson, Danielle - FNP Meier, Nicole - PA-C Mickelson, Scot - DO Miller, Carol - FNP-C Mittleider, Erica PA-C Moe, Jason - MD Moen, Douglas - MD Murphy, Louise - MD Murthy, Sanathana - MD Nath, Himadri - MD Nelson, Diane - MD Nelson, Matthew - MD Neugebauer, Leah - FNP-C, WHNP-BC Nicholson, Beth - DPT Oatfield, Robert - MD Obritsch, Jerry - MD Orchard, Jeffrey - MD Oyerinde, Koyejo - MD, FAAP Pathroff, Robert - MD Patton, Cindy - OTR/L Paulo, Monica - MD Paulson, Rick - MD Peake, Michelle - OTR/L Pengilly, Danette - GNP-BC Penn, Jeremiah - MD Peterson, Douglas - MD Pierce, Troy - MD Pierson, Ashley - MD Piyamahunt, Arkapol - MD Pokharel, Saurav - MD Price, Brandon - DO Quisno, Jacqueline - MD Raducu, Elena - MD Raducu, Radu - MD Rao, Vijay - MD Rauta, Radu - MD Rosen, Rachel - FNP-BC Rudnick, Andrea - NP-C Ruhland, Jessica - MD Russo, Crystal - PA-C Russo, Kyle - MD Sanches, Marsal - MD Sandness Nelson, Heather - MD Sauter, Shannon - MD Schaff, Kristen - PA-C Scherr, Steven - MD Schindler, Karen - RD, LRD, CDE Schirado, Michael - MD Schmidt, Jared - MD Schmidt, Jenny - RD, LRD Schorr, Stephen - MD Schuler, Erica - PT Schwartz, Julie - MD Sebastian, Nicole - MS, CCC-SLP Seifert, Shelly - MD Sethi, Muhammad - MD Siemens, Lindsey - PA-C Smith, Jeffrey - MD Smith, Lori - RD, LRD, CDE Songsiridej, Nowarat - MD Staloch, Coleen - FNP, C/PA-C Steffan, Haley - MS, CCC-SLP Steinle, Jill - MD Stork, Brad - FNP-C Strand, Megan - MD Szymanski, Kila - PA-C Tangedahl, Guy - MD Tanous, Robert - DO Tarver, Daniel - MD Thomas, Kayla - FNP Timothy, Promila - MD Toman, Kristie - DO Tongen, John - AuD, CCC-A Torske, Brian - NP-C Trana Pagel, Bobbie - FNP-BC Traxinger, Stephanie - DO Ulberg, Melissa - FNP-C Van Klootwyk, Michelle - FNP-BC Vander Linden, Jackie - PA-C Vaughan, Makayla - DNP, FNP-C Volk, Charles - MD Wanner, Kay - RD, LRD, CDE Wells, Robert - MD White, Peter - MD Wiedrich, Sara - FNP-C Wilder, Andrew - MD Wisdom, Marissa - MD Witt, John - MD Wolff, Lori - PA-C Wongjirad, Chatree - MD Wright, Sharon - ANP Wutzke, Jesse - MS, OTR/L Yearsley, Steven - MD Zacher, Carla - MD Zaidi, Syed W. - MD
Allergy Anesthesiology Arthritis-Rheumatology Audiology Cardiac Electrophysiology Cardiology Cardiology Pediatric Cardiovascular & Thoracic Surgery Critical Care Dermatologic Surgery Dermatology Diabetes Ear, Nose & Throat Emergency & Trauma Medicine Employee Assistance Program Family Medicine Gastroenterology General Surgery Hand Surgery Hematology Hospital Medicine Infectious Diseases Intensivists Internal-Adult Medicine Interventional Cardiology Interventional Radiology Maternal-Fetal Medicine Laborist Neonatology Nephrology Neurology Neuropsychology Neurosurgery Nutrition Obstetrics & Gynecology Occupational Medicine Occupational Therapy Oncology Ophthalmology Orthopedics Otolaryngology Pain Medicine Palliative Care Pathology Pediatric Cardiology Pediatric Neurology Pediatrics Physical Medicine & Rehabilitation Physical Therapy Plastic & Cosmetic Surgery Plastic & Reconstructive Surgery Podiatry Psychiatry (Adult & General) Psychiatry (Child & Adolescent) Psychology Pulmonology Radiation Oncology Radiology Rheumatology-Arthritis Speech Therapy Urology Vascular Surgery
- None - Advanced Surgical Arts Center Aesthetic Center of Plastic Surgery Archway Mental Health Services Becker Plastic Surgery Center Biron D. Baker Family Medicine, PC Bismarck Cancer Center CHI St. Alexius Health CHI St. Alexius Health Arthritis Clinic CHI St. Alexius Health Family Medicine - Garrison CHI St. Alexius Health Heart & Lung Clinic CHI St. Alexius Health Infectious Disease Clinic CHI St. Alexius Health Interventional Radiology Clinic CHI St. Alexius Health Mandan Medical Plaza CHI St. Alexius Health Minot Medical Plaza CHI St. Alexius Health Neonatology Clinic CHI St. Alexius Health Nephrology Clinic CHI St. Alexius Health Neurology Clinic CHI St. Alexius Health Neurosurgery Clinic CHI St. Alexius Health Occupational Medicine CHI St. Alexius Health Pain Clinic CHI St. Alexius Health Pediatric Cardiology Clinic CHI St. Alexius Health Physical Medicine Clinic CHI St. Alexius Health Sleep Center CHI St. Alexius Health Urology Clinic Dakota Eye Institute - Main Clinic Dakota Eye Institute - North Clinic Dakota Foot & Ankle Clinic Eye Clinic of North Dakota Grube Retina Clinic, PC Jeffrey Smith, MD, PC Mid Dakota Clinic Mid Dakota Clinic 9th & Rosser Main Clinic Mid Dakota Clinic Center for Women Mid Dakota Clinic Dermatologic Surgery, Cosmetic & Laser Center Mid Dakota Clinic Gateway Dermatology Mid Dakota Clinic Gateway Mall Clinic Mid Dakota Clinic Gateway Mall Pediatrics Mid Dakota Clinic Kirkwood Mall Clinic Mid Dakota Clinic TODAY Clinic 9th & Rosser Mid Dakota Clinic TODAY Clinic Gateway Mall Mid Dakota Clinic University of Mary Student Health Clinic Mid Dakota Clinic WorkLife Occupational Medicine Missouri Basin Anesthesia Northland Community Health Center - McClusky Northland Community Health Center - Turtle Lake Pathology Consultants Spine, Orthopedic and Pain Center The Bone & Joint Center UND Center for Family Medicine
Name of Patient:
Person requesting appointment:
Last Name of Person requesting appointment:
Patient's Date of Birth:
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Patient's Zip Code:
Confirm E-mail Address:
Insurance Policy Number:
Insurance Group Number:
Reason for appointment and/or primary complaint:
When would you like to be seen?
Which day of the week do you prefer?
What time of day do you prefer?
How would you like us to confirm this appointment?
Additional information or comments: