Appointment Change Request

Fraser Appointment Change Request

Not for Day Treatment, ABA, Group Services, and for non clinical services (Home-Based, Housing, Career Planning and Employment, or Waiver, Rule 185, or VADD Case Management)
If your appointment is within one (1) hour, please call Client Services at 612-767-7222
Client Name*

First NameLast Name
Client DOB*

MonthDayYear
Clinician Name
Location*
Service Type*
Appointment Details*

MonthDayYear
Date
Time MinutesAM/PM Option
I would like to:*

Convert existing appointment to telehealth at the same date/time (preferred)Request to reschedule appointment to another appointment date/timeCancel appointment - one appointment onlyCancel appointment - all future appointments
I would like to:*

Request to reschedule appointment to another appointment date/timeCancel appointment
Note: request to reschedule is not guaranteed and is subject to appointment availability
Person Completing the Form:*

First NameLast Name
Relationship to Client*
Email Address:*
example@example.com
Preferred phone number*
Email Insert
CANCEL

CANCEL
CONVERT

CONVERT
RESCHEDULE

RESCHEDULE
Should be Empty:

Fraser Appointment Change Request