224 Circle Drive
Traverse City, MI 49684
ph: (231) 935-0600
fax: (231) 935-0613

Forms

In order for us to provide you will the best possible care; it is important that we have the most updated information for you.  All patients are requested to complete a patient information form and symptom questionnaire annually.  We have provided downloadable, printable forms for your convenience to be filled out prior to your visit.  Before your scheduled appointment:

If you are a New Patient please print and complete the following:

If you are an Established Patient, please print and complete the following:

Prescription Refill Request:

If you would like to either mail or fax a request for a prescription refill, please print and complete:

You may call our prescription refill line at (231) 932-4920.

Medical Records Release:

If you will be transferring your care to Milliken Medical, please print and complete the following form and give to your current physician’s office so that your records will be transferred to us.

Download our Patient-Centered Medical Home Brochure.

You may also view and print a copy of our Privacy Policy.