Online Contact Form

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

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

To RSVP to a presentation: Select Presentation from the Inquiry Regarding drop down menu below. Please let us know how many are attending with you and the date or location of the event you plan to attend. Thank you.

Contact info

Office Name 

Full Name 

Phone Number 

Fax Number 


Inquiry Regarding 

Preferred method of response contact 



Conditions of Online Contact Form
Southern Michigan 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 call please call the office you are seen at and select the Rx Refill or Nurses option. Number below. For convenience, M-F if an office is closed, calls are forwarded to one of the open locations.

If this is an emergency, dial 911.

These forms are downloaded on a daily basis. You can expect to get a response about within two business days of the form being submitted.

This form is for non urgent contact only, if you need more immediate attention, have questions about your treatment or to schedule a follow up appointment you will need to call the location you are seen at to have these issues addressed. Main phone numbers below:

Portage Direct: (269) 329-2887
Marshall Direct: (269) 781-3561
St. Joseph Direct: (269) 429-386