Submit Referral

Thank you for choosing to refer your patients to us, Colorectal Clinic of Michigan.Please complete the referral form below and our dedicated team will follow up.If this is an emergency referral, please contact our office directly at 586-343-8717

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Patient's Information

Patient's Name*
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Referring Physician Information

Referring Physician's Name*

What is the reason of referral?

This field is for validation purposes and should be left unchanged.