Northern Michigan Medicine and Pediatrics

New Patient Request Form

Please read through all instructions below:

FOR NEWBORNS - Call the office (do not complete this online request) if you have a newborn that needs to be seen post discharge or plan to delivery within 2 weeks. 

  • Submit one form per patient.
  • A valid email address is required.
  • DO NOT contact the office regarding the status of your request. 
  • Our practice is only accepting a very limited number of new patients.
    • We will email you if we cannot take you on as a new patient.
  • Average wait time from online application submission to new patient appointment is 8-12 weeks for adults, and 3-6 weeks for pediatrics. 
  • If you are in need of more urgent care, seek treatment at a walk-in clinic.  
  • For help finding another PCP, contact Munson HealthLink at 231-935-5886 or via email at


* = required

(Include any previous last names)

(if no insurance, enter "cash pay")


Contact Us

Main:  231-935-0614

Fax:  231-935-0832

Patient Portal

We accept:


Contact our office to verify
accepted insurance plans and
additional payment options

Northern Michigan Medicine and Pediatrics

3643 West Front Street , Ste. C
Traverse City, MI   49684

Phone: 231-935-0614
Fax: 231-935-0832