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*

First Last

Patient's DOB*

Contact/Patient's Phone Number*

Contact/Patient's Email*

Patient's Insurance*

Referring Physician Information

Referring Physician's Name*

Referring Physician's Phone Number*

Referring Physician's Email*

What is the reason of referral?

Please Specify if there is a Doctor preference*

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