Dr. Mary Lee M.D., P.C.
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New Patient Registration Forms
File Size:
198 kb
File Type:
pdf
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Questions, Appointments, or refill requests
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Indicates required field
Patient Name
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First
Last
Enter Patients First and Last Name
Patients Email
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Please enter the best email address to reach the Patient.
Patients Phone Number
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Please enter the best number to reach the Patient. Include area code as well.
Select One of the following
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Question for Dr. Mary Lee
Request an Appointment
Request a Refill on a Prescription
Please select an option from the list. If you have multiple requests, please use the Question option and include all appropriate information.
Question, Appointment, or Refill Request
*
Please make sure that you include he Patients full Name, Birth Date, and Contact phone number. If requesting a refill of a prescription make sure to include the name of all medications. If you have an emergency please call 911 or go to the nearest emergency room as this emails are typically reviewed only during business hours.
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5799 West Maple Road, Ste. 163
West Bloomfield, MI 48322
Office: 248-419-5111
Fax: 248-419-5112
Home
About Us
Resources & Requests
Urgent Care Centers
Dr Mary Lee
News
