Appointments Required fields are marked with * Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!Appointment Type: Physician Prompt- We take extra effort to accommodate your appointment as quickly as possible, generally within 1-2 weeks. - Initial Visit + 3 month support ($1395) - $100 discount applies when forms are received prior to visit - $200 non-refundable deposit is required to book the Prompt Appointment.Appointment Type: Physician Standard- Implies that we provide an appointment based on availability. - Initial Visit + 3 month support ($1175). - $100 discount applies when forms are received prior to visit. - $200 non-refundable deposit is required to book the Standard Appointment.Appointment Type: Telemedicine (Video or Phone) Consultation- We provide an appointment based on availability. - Initial Visit ($1475). - $100 discount applies when forms are received prior to visit. - A $200 non-refundable deposit is required to book the Standard Appointment.What type of appointment are you requesting?Physician PromptPhysician StandardTelemedicine (Video or Phone) ConsultationWere you referred by a healthcare provider?YesNoIf yes, who referred you?Your name or nickname*Your AgeYour genderFemaleMalePrefer not to sayDo you plan to use insurance for some services? PPO Covered under Medicare NoEmail* Phone*Best time to call you?Preferred day of the week? Monday Tuesday Wednesday Thursday Friday SaturdayPreferred time of day?AMPMDo you want an early morning (before 8:30am), after hours(after 5pm) or Saturday appointment?YesNoIf we could accommodate an appointment in the early morning, after hours, or on Saturday, are you willing to pay an extra $100?YesNoHow quickly do you need to be seen?Reason for your visit or additional comments:Privacy Policy*I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
