Appointment Request


Migraine \| Other Head Pain and Neck Pain \| Other Pain Disorders	For Immediate Assistance

Call us:
(734) 677-6000 (800) 518-3639

If your situation is urgent please do not hesitate to call us at: (734) 677-6000 or (800) 518-3639

If you would like to schedule an appointment, please complete the form below, then click on Submit.

Referring physicians and physicians' offices can also print and submit a New Patient Referral Form via fax.

Please do not use this form to submit medical questions to MHNI.

Fields marked with * are required

Contact Request


	Courtesy Title:
	* Full Name:
	Job Title:
	* Street Address:
	Address Part 2:
	* City:
	The above address is a:
	* State:
	OR * Province:
	* Zip/Postal Code:
	* Country:
	* Daytime Phone:	() Ext:
	Fax:	()
	* Email Address:
	* Confirm Email Address:
	Messages for MHNI: The message area below should not be used by individuals who have a clinical circumstance under question which needs direct involvement of a medical professional. Regretfully, we are unable to respond to correspondence and/or requests of a clinical nature through the Internet. Individuals who need direct involvement of a medical professional should contact him/her directly. The message area below can be utilized to provide comments regarding this website or to request specific educational materials on a headache and/or pain topic.

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