Request a Clinical Consultation or Videoconference

Contact Name: *    
E-mail: * Department:
Telephone Number: * Fax Number:
Type of Event: Patient Education  Conference 
  Administrative Meeting Clinical Consultation
Date of Event: *    
Time of Event
 (from):
*
                 (to):
*
Estimated Number of Attendees:    
Additional
Infomation:		    

(*):  Required Fields

 

   This form will be sent to telemedicine@umich.edu when you click on the
"Send Message" button

You will receive confirmation of this request via e-mail. If you do not receive
confirmation within 24 hours, please call (734) 615-8278
 

 

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