• Practice Hours
  • After Hours

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.

  • 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