Request Appointment | Northern Neurology 2026

Request an Appointment

Please complete this comprehensive request form for our Fairbanks, Wasilla, or Anchorage clinics. To facilitate your neurology care, ensure your Date of Birth and a brief reason for your visit are accurately provided. This information is processed securely under HIPAA privacy standards.

If you use this form, please allow at least 48 hours before you receive a call to schedule, this gives us time to process and look for a space available depending on your need and the urgency. We appreciate our patients and continually strive to make things as easy as possible!

Fill out the form below to request an appointment or call us at 907-416-6594

New patient appointment request form

First name

Last name

Birthday

Month

Day

Year

Phone

Do we have your permission to use your email address for health information?

YES

Multi-line address

Country/Region

Address

City

Zip / Postal code

Insurance information: Primary insurance and Secondary (if applicable) *

Please let us know what you need to be seen for: (please give us your diagnosis, specific symptoms, or pertinent family medical history regarding your diagnosis or symptoms - for example hereditary conditions)*

What medications/treatments have you tried or currently are on for this neurological condition? Are you in need of immediate refills? *

Do you a have primary care provider? (Please list their name/ clinic) *

Do you have access to your previous medical records and will you be able to bring them with you or drop off prior to your appointment?*

YES

Request an Appointment

Fill out the form below to request an appointment or call us at 907-416-6594New patient appointment request form

Fill out the form below to request an appointment or call us at 907-416-6594

New patient appointment request form