Schedule Appointment Online

DO NOT USE THIS WEB PAGE FOR EMERGENCY MEDICAL CONDITIONS

The following form is provided to enable you to request an appointment with Southern Minnesota Surgical Inc. You will receive a follow-up phone call from our office within 48 hours of submission of this request. Please call our office directly if you need a response more quickly. This form should not be used for specific health related questions.

Please enter your name, e-mail address, your telephone number and describe what this appointment is pertaining to so we can contact you to confirm an appointment time.

*First Name
*Last Name
*Date of Birth
*Phone
xxx-xxx-xxxx
Reason for Appointment
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