Patient insurance information and Medical history

Please fill Form 1 and 2

Form1 -Demographic (patient and insurance) information: CLICK HERE

Form2 -History : CLICK HERE

Downloadable forms are also available in these sections. 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

micrs3106@gmail.com