Virtual Appointment Intake Form

NOTE: This form must be submitted prior to your Virtual appointment.  At the end of this form you will be asked to upload a copy of your Proof of Michigan Residency, and MMMP Patient ID Card if you are renewing.  The only image types that are accepted are .jpg, .jpeg, and .png.  IMPORTANT: iPhone users. Newer iPhones save images in HEIC format. This file format is not accepted.  Please read this to easily change HEIC to JPG format. You will receive a copy of these forms via email once complete.