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  • Practice Hours
    734-362-5100

Referrals

You can now request a referral from our Customer Portal.

Patient Portal URL
https://health.eclinicalworks.com/familyhealth

Before using this service, please be aware of the following:

  • This page is encrypted for your safety . Any information you provide is secure.
  • Filling out this form will notify our office that you are requesting a referral.
  • Notifications are checked several times daily until 4:00 pm
  • Do not submit more than one request, as this may cause confusion and further delay
  • Please allow 24 hours for your referral request to be processed
  • We will contact you if there are any problems with your referral request
  • If this is an emergency, please call our office at (734) 362-5100

Please fill out this form in it’s entirety. All fields are required.

  • Sign In – Patient Portal

    • Ask questions
    • Request prescription refills and referrals
    • View your personal health
    • Examine your statements
    Sign In Now

      • Patient Information

      First Name

      Last Name

      Date of Birth

      Your Phone

      Your Email

      Referral Information

      Place of Referral

      Doctor's Name

      Doctor's Phone

      Doctor's Fax

      Date of Appointment

      Reason for Referral

      If you are requesting a referral for a test, please answer the following:

      Name of Test

      Date of Test

      Test Location

      Location Phone Number

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