Forms

Secure Online Forms
For your convenience, several secure, online forms are available for your use. Under Facility, use the Botsford Clinic System form to pay your bill.

  • Online Payment
    You can use this convenient online form to pay your bill from our office. Please fill out all areas.

  • Patient Registration
    For our new patients. You can help us with your registration by filling out this form and submitting it prior to your first appointment.

  • Prescription Renewal Request
    Please use this form to request a prescription renewal from our office. We will respond within one business day.

  • Referral Request
    If you have seen one of our doctors and they have told you to see a specialist, please make an appointment with that specialist. Ten days are required for filling a request for referral, unless this is an emergency. This is due to the processing time the insurance company requires for authorization.

    The referral will be faxed or mailed to the specialist's office for your convenience. Please check with the specialist the day before your appointment to see if they have received your referral.