This form helps prospective patients connect more efficiently and explore whether this provider will be a good fit. Completion of this form is not a guarantee of treatment nor does it establish a doctor-patient relationship.
If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead, call 911 or go to your closest emergency room.
I acknowledge and wish to proceed.
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