* Indicates a required field.
Contact Name:
Relation to Patient:
*Home Phone:
Work Phone:
*Email Address:
Scheduling Information
Have You Visited our office before?
Yes
No
Which office will you be visiting: Fridley Office Maplewood Office
Which Doctor would you like to schedule an appointment with: Dr. Gregory Kraupa Dr. Bradley Richter Dr. Mitchell Albers Dr. Steven Nauman Dr. Tina McCarty Dr. Komal (Mahnia) Madan
What type of exam are you scheduling an appointment for: Complete Exam - Existing Patient Complete Exam - New Patient Complete Exam with Contact Lens Evaluation - Existing Patient Complete Exam with Contact Lens Evaluation - New Patient Computer Vision Syndrome Evaluation - Not a complete exam Contact Lens Evaluation only Office Visit - Non-Emergency Office Visit - Emergency (CALL OUR OFFICE IMMEDIATELY!)
Please enter up to three times that would work well for you ( i.e. "Thursday mornings" or "Friday afternoon").
Confirmation:
How do you prefer to be contacted? Email Phone Both