Online Contact Form

Use the form below if you have non medical questions related to scheduling an appointment, billing questions or if you are a physicians office and would like more information about our practice. Patients interested in setting up a non urgent new patient appointment may do so by using this online form.

Allow at least 2 business days for response to your inquiry. Thank You!

Contact info
Date 

Office Name 

Full Name 

Phone Number 

Fax Number 

Email 

Inquiry Regarding 

Preferred method of response contact 

Notes 

Disclaimer 
Conditions of Online Contact Form

Tri-County Pain Consultants values your privacy. We have taken all reasonable precautions to ensure that your information is securely transmitted. This contact form should be used for routine purposes only. If this is an early or urgent refill, please call our office and select Rx Refill or Nurses option. The number to the clinic is (248) 735-8272.

If this is an emergency, dial 911.

These forms are downloaded on a daily basis. You can expect to receive a response within two business days; this form is for non-urgent issues. To schedule a non urgent follow up appointment, please call our office directly.