Save yourself some time and fill out this form before you arrive for your first appointment. Click on the interactive form and complete it in your browser. PLEASE NOTE: In order to save your information into the form, you must select the printer icon in the upper right hand corner, then select “Save as PDF” for your Destination.

After completing this form, you can print it and bring it with you to your first appointment.
We look forward to seeing you!

You may also wish to submit your completed demographic form using our secure webform prior to your appointment. If so, please complete the following fields and submit your attached completed demographic form below, and your information will be entered into your private electronic record.

Please do not submit this form if you do not have your first appointment scheduled with us; call us at 313-656-4052 or submit an appointment request online and we will assist you with making your first appointment!

* indicates required field

Acceptable file types: PDF.
Maximum file size: 1mb.
Demo Form