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APPOINTMENT REQUEST FORM

* Note: Please allow 1 business day for our staff to contact you to schedule an appointment. If you can't wait the 24 hours to make an appointment, please call our office at 248-419-5111.
If this is an emergency, please go to your nearest local hospital or call 911.
I would like to schedule an appointment for:
Myself My Child Other
New or Return Patient:
NEW RETURNING  
Patients Name
Are there any changes with your insurance?
YES NO  
If YES, please explain:
Phone Number:
Email:
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SYNERGY HEALTH P.C.
33200 W. 14 Mile Road, Suite 150
West Bloomfield, MI 48322-3549
Office: 248-419-5111
Fax: 248-419-5112