New Patient Online Enrollment Form
You can use this online form to enroll in our clinic.
Once we receive your information we will contact you and talk with you about your qualifying condition(s) and possibly set up an appointment for you to see one of our doctors.
If your qualifying condition is Chronic Pain, Severe Nausea, Muscle Spasms, or Seizures, please specify what these ailments are the result of. For example, if you have Chronic Pain, then this may be the result of Degenerative Disk Disease, or if you have Seizures, this may be the result of having Epilepsy etc.
You have the option of having us pre-screen your condition prior to seeing one of our doctors to see if you would be a candidate. You can do this by either calling or stopping in our clinic Monday - Friday 9-5 or you can just fax your records to us at 517-292-2487 any time.
If you have any trouble with this form, you always have the option of calling us and enrolling over the phone.