For referring providers

Refer a patient.

A streamlined, provider-to-provider path, kept separate from the patient intake flow. Send the essentials and the office will coordinate scheduling and records.

This form is not a HIPAA-secure transfer channel. Share only what's needed to initiate contact; send imaging and records through your secure system or by calling the office at (586) 803-1220.

Initials only: no full identifiers or PHI in this form.

A brief clinical summary. Keep it high-level; send full records securely.