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 - $1395Details- We take extra effort to accommodate your appointment as quickly as possible, generally within 1-2 weeks. - Includes Initial Visit + 3 Months Support ($1395) - $100 discount applies when you complete our forms prior to visit - $200 non-refundable deposit is required to book the Prompt Appointment.Appointment Type: Physician Standard - $1175Details- Implies that we provide an appointment based on availability. - Includes Initial Visit + 3 Months Support ($1175). - $100 discount applies when you complete our forms prior to visit. - $200 non-refundable deposit is required to book the Standard Appointment.Appointment Type: Telemedicine (Video or Phone) Consultation - $1475Details- We provide an appointment based on availability. - No Support - $100 discount applies when you complete our forms prior to visit. - $200 non-refundable deposit is required to book the TeleMedicine Appointment.What type of appointment are you requesting?Please choose after reviewing abovePhysician PromptPhysician StandardTelemedicine (Video or Phone) ConsultationWere you referred by a healthcare provider?YesNoIf yes, who referred you?Your name or nickname*Your AgeYour gender Female Male Prefer not to sayDo you plan to use insurance for some services? PPO Covered under Medicare NoEmail* Phone*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.CAPTCHANameThis field is for validation purposes and should be left unchanged.
