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Pre-Examination Form.

Group Pre-Examination Form...

Please fill out this simple form and submit it prior to your examination. If you do not already have a scheduled appointment, you may fill out this form and a representative will call you to answer any questions and schedule an appointment for you. Please allow 24-48 hours for response.

* denotes a required field

First Name: *
Last Name: *
Address: *

City: *

State: *
Zip: *

Number of Travelers in Group:
Adults: *

Destination Country:

Departure Date: *
Return Date: *
Ins. Provider: *
Insurance Type: *

Previous International Travel Experience? *

Do You Have An Appointment Scheduled? *

Would You Like Us To Call And Set An Appointment? *

Questions or Comments:

Office hours are Monday through Friday:
9:00 a.m. until 12:00 noon and 2:00 p.m. until 5:00 p.m.
We accept cash, check, Visa and Mastercard.

C. Michael Lewis, D.O.
G-8195 S. South Saginaw Street
Suite B
Grand Blanc, MI 48439

Phone: (810) 694-5393
Toll Free: 800-966-5393
Fax: (810) 694-5394

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