Patient Forms

General Information

For current patients with non-urgent requests and new patients wishing to schedule an appointment, please leave a message at our office -734-973-3030 - or you may email your request to us at This email address is being protected from spambots. You need JavaScript enabled to view it..

Phone and email messages are checked on Mondays, Wednesdays and Fridays during office hours. Your request will be answered on the next business day (usually within 48 hours).

If you have need for a referral (Blue Care Network and sometimes HAP) or want an appointment or need a prescription or remedy refill, you can do one of three things: 1) download the request form online, fill in the areas you need, save the request form as a file to your computer and email it as an attachment to This email address is being protected from spambots. You need JavaScript enabled to view it., 2) print the request from and fax it to 734-973-3057, or 3) call the office directly and either leave a message on our voice mail or with one of the office managers. If you are a new patient and want to fill the forms out at the office, please come ten minutes early to fill these out.

 

Appointments

To make new appointments, cancel and reschedule appointments please leave a contact number.For appointment requests, give us at least two preferred times for scheduling.

___________________________________________________________________________

___________________________________________________________________________

 

Referrals and Requisitions

If you want Dr. Chernin to complete a referral to a specialist or you need a requisition for lab work or other test, we need the following information:

  • Your Name:__________________________
  • Date of Birth:__________________________
  • Contact Phone Number:__________________________
  • Date Needed By/Date of Appointment:__________________________
  • Diagnosis/Reason for Visit:__________________________
  • Insurance:__________________________
  • Name, Contact Number and Fax where referral is going:__________________________
  • How you want to receive (pick up at our office, US mail, fax):__________________________

 

Prescription Refills

To have an existing prescription renewed please include the following information:

  • Your Name:__________________________
  • Date of Birth:__________________________
  • Your Contact Phone Number:__________________________
  • Date Refill Needed By:__________________________
  • Prescription name and dosage:__________________________
  • Quantity and Refills requested :__________________________
  • Pharmacy, Contact Number/or Fax where prescription referral is going:__________________________
  • If mail order pharmacy include your pharmacy id # and mailing address:__________________________

 

If you wish to obtain a new prescription, it is very likely you will be asked to schedule a visit with Dr. Chernin first.

 

Remedy Refills

  • Your Name:__________________________
  • Your Contact Number:__________________________
  • Remedy name and dosage (ie 30c, 200c):__________________________
  • Quantity:__________________________
  • Date Needed/When you plan to pick it up:__________________________
  • Mailing instructions/address if you are a mail order patient:__________________________

 

Copy of Medical Records

  • Your Name:__________________________
  • Date of Birth:__________________________
  • Your Contact Number:__________________________
  • Copy of Release of Information:__________________________
  • Date Records Needed by:__________________________
  • Records Needed (ie specific test result, most recent visit, etc):__________________________
  • Name, Number and Fax where records are being sent :__________________________
  • Records Obtained solely for Insurance/Legal Purposes are generally charged a fee to the company requesting them:__________________________

 

EMERGENCY

FOR EMERGENCIES PLEASE DIAL 911 or GO TO YOUR NEAREST EMERGENCY ROOM

FOR URGENT REQUESTS (CURRENT PATIENTS ONLY) – Call

734 476-2621.

 

Miscellaneous forms