Botsford Cancer Center
27900 Grand River Ave.
Farmington Hills, MI 48336
(248) 471-8120
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Botsford Hospital Main Campus
28050 Grand River Ave.
Farmington Hills, MI 48336-5919
(248) 471-8000
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The Botsford Cancer Center

Request an Appointment

Use this form for non-urgent appointments only.
For urgent appointments within 48 hours, please contact us by phone at (248) 471-8100.
An asterisk (*) indicates required information.

After you submit this form, someone will contact you within 48 hours during normal business hours, Monday through Friday, 9:00 a.m. to 5:00 p.m., except holidays. If you do not hear from us within that timeframe please contact us by phone at (248) 471-8100.

PATIENT INFORMATION
First Name*:
Last Name*:
Date of Birth*:
Primary Phone*:
Alternate Phone:
Email Address*:
   
Physician Name:
Physician Phone:
   
APPOINTMENT INFORMATION
Procedure(s) Needed: Cancer Consultation Cancer Diagnostic CT Scan Cancer Second Opinion
Preferred Day of Appointment: Mon. Tue. Wed. Thu. Fri. Sat. Sun.
Preferred Time of Appointment: Morning Afternoon Evening
Best Phone Number to Use:
Best Time to Call: 8-10am 10am-12noon 12noon-2pm 2-4pm 4-6pm
   
INSURANCE INFORMATION
Primary Insurance:
Insurance ID or Policy Number:
Group Number:
Name of Insured (if different from patient):
Comments/Questions:
How did you hear about us?
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