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Appointment Request & Sliding Scale Application
Unfortunately, due to grant funding our sliding scale rates are only available to residents of Rutherford, Polk, McDowell and Cleveland Counties in North Carolina. If you do not live in one of these counties please put "N/A" within the Sliding Scale/Income section. Thank you
Email *
Client Name *
Mailing Address (including city) *
Mobile Phone # *
OK to text? *
Client Birthday *
Reason for Visit *
If you are filling this for out for someone else, what is your name and relationship?
How did you hear about us? Or who referred you to us? *
Do you have insurance? (i.e. BCBS, United Healthcare, etc) *
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