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doctor checking document medical questionnaire form

To help us get a better understanding of your condition or concerns, we may have to learn more about your medical history from your current general practitioner. Please fill out the below Medical Record Release form and bring it with you to your next appointment.


Allergy & Immunology Associates of Michigan’s medical records fee is in accordance with the Medical Records Access Act, Public Act 47 of 2004, MCL section 333.26269. The Department of Health and Human Service sets the rate health care providers may charge for copies of records.  Please be advised there may be a charge for copies of medical records and additional requests to other physicians.

Your premier allergist / immunologist in the Ann Arbor area.

Convenient patient forms

*Please fill out patient demographic information and fax your form to the appropriate office below for the nurse/physician to complete. Please be sure to specify the brand of epinephrine the patient is currently using.


Ann Arbor/Canton/Chelsea – fax (734) 434-6212

Novi/Brighton – fax (248) 349-3778

West Bloomfield/Livonia – fax (248) 932-0182