To schedule an appointment please complete the new patient and credit card information below.

A credit card is required to hold your evaluation. You will not be charged until after your appointment. Please be sure to review our cancellation policies. New patient evaluations cancelled 48 hours before the start of your appointment will be charged a $50 late cancellation fee.

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referred By

Primary Care Physician's Address + Phone

Reason for Evaluation

Credit Card Holder Name

as shown on card

First Name

Last Name

Card #

Expiration Date

mm/yy

Billing ZIP code

CVV#

While we do not accept insurance, the office can provide you with a superbill so you can submit directly to your insurance if you choose to do so. Will you require a superbill?

yes

Please select your billing schedule.

Superbills are sent via email. Please confirm the personal email address you would like us to send them to. *We cannot email them to your insurance company.*

* IF THIS IS AN EMERGENCY PLEASE CONTACT 911 OR GO TO THE NEAREST EMERGENCY ROOM *