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NOTE: Insurance Verification is completed the day prior to the appointment. If no insurance is provided before your appointment, you will be considered self-pay. The rate is $200 for an initial evaluation and $150 for follow-up appointments.
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Self-Pay
Insurance
We will collect $25 upon scheduling of your visit. You may cancel up to 24 hours before your appointment, afterwards this will be non-refundable
I have read and reviewed Privacy Forms and Liability Forms. I understand submission of this form does not guarantee my appointment spot.
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New Patient
Select one... *
Female
Male
Communication Preference *
Contact by Email
Contact by Text
NOTE: Insurance Verification is completed the day prior to the appointment. If no insurance is provided before your appointment, you will be considered self-pay. The rate is $200 for an initial evaluation and $150 for follow-up appointments.
Appointment Type *
Self-Pay
Insurance
We will collect $25 upon scheduling of your visit. You may cancel up to 24 hours before your appointment, afterwards this will be non-refundable
I have read and reviewed Privacy Forms and Liability Forms. I understand submission of this form does not guarantee my appointment spot.
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
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