Please fill Form 1 and 2

Form1 - Demographic (patient and insurance) information: External link opens in new tab or windowCLICK HERE

Form2 - Medical History : External link opens in new tab or windowCLICK HERE

Please upload pictures of your insurance cards and driver's license to complete the registration process efficiently by clicking External link opens in new tab or windowhere

Downloadable forms are also available in the link below. Please fill then mail, fax or email to:

MIchigan Colon and Rectal Surgery (Dr: _____  )

3106 S Wayne Rd

Wayne MI 48184

Fax 734 722 4815

External link opens in new tab or windowmicrs3106@gmail.com

Make a payment External link opens in new tab or windowCLICK HERE

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