You can now request a referral from our Customer Portal.
Patient Portal URL
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.