Book Appointment Online DMC RIM

Request An Appointment

Complete the form below or call the Physician Referral Service toll-free at 888-362-2500 between 8 a.m. and 5 p.m., Monday through Friday.
A Referral Advisor will call you within two business days to assist you in coordinating with the DMC Physician you have selected.
Note: This feature connects patients with physicians through a three-way conference call; the Referral Service does not have direct access to physician schedules. If you prefer you may contact the physician office directly.

Patient First Name ^*

Patient Last Name ^*

Zip Code: ^*

Patient Middle Initial

Patient Birthdate ^*

(mm/dd/yyyy)

Gender

Parent/Guardian Name (If applicable)

Requestor’s Name, if different from patient

Address ^*

Apt Number

City ^*

State:

Phone ^*

000-000-0000

Alternate Phone

000-000-0000

Best time of day to Call

Email ^*

Confirm Email ^*

Select a choice

Please add me to the Detroit Medical Center Email Update list.

Insurance Provider

Plan Number

Policy Holder

Are you a new patient ^*

Yes

Day 1

(mm/dd/yyyy)

Time

(HH:MM AM/PM)

Day 2

(mm/dd/yyyy)

Time

(HH:MM AM/PM)

Day 3

(mm/dd/yyyy)

Time

(HH:MM AM/PM)

Hospital: ^*

Reason for Appointment/Diagnosis ^*

Additional Information Regarding this request

Select a choice

I would like DMC to email me information about its programs, events and services

Physician

Specialty