Request an Appointment

This form is for non-urgent appointments only. Appointment requests are processed in one to two business days.

If you do not have a MyChart account, sign up now
If you are having an emergency, call 911 or go to your nearest emergency room
Request a same-day primary care appointment
Call us:
- Southeast Michigan Patients: (800) 436-7936
- Jackson or South Central Michigan Patients: (517) 205-4800

How Can We Help You?

Reason for Appointment

Specialty

Doctor's Name (if known)

Preferred Dates and Times

Preferred Location

Other Location

Patient Information

First Name

Last Name

Date of Birth

Enter MM/DD/YYYY format

Address

City

State/Province

Zip Code/Postal Code

Phone Number

Insurance Information

Insurance name and group number

Contact Name

Please include your name if you are making this appointment for someone other than yourself

Authentication

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