Appointment Request - Choulet Wellness

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Please fill out the information below to request an appointment at Choulet Wellness. Our Client Care Coordinator will reach out to you within 48 hours of receiving your completed request. This appointment request form is confidential. In compliance with the Health Portability and Accountability Act "HIPAA" (rule 104-91), please know that communications over the internet are not guaranteed to be secure. There exists a possibility that information you include in this form can be intercepted and read by other parties besides the staff at Choulet Wellness. Please call us at 480-448-6571 if you prefer to request an appointment by phone.

Email *

Name (First+Last): *

Age of Client: *

Cell Phone Number *

How were you referred to Choulet Wellness? *

What is your zip code? *

Our physicians and clinicians can only see patients located within the state of Arizona, per medical licensing laws.

Which service are you requesting an appointment for? *

Psychiatry (medication management appointment with physician)

Psychiatry (medication management + therapy appointment with physician)

Executive Performance Therapy with Dr. Brook Choulet (M.D)

Therapy with psychologist or counselor

Sport & Performance Psychology with Dr. Shelton

Nutrition Coaching

Botox/Filler Appointment with Certified Nurse Injector

Other:

I understand that the providers at Choulet Wellness are not in-network with any commercial health insurance plans. I acknowledge that I am responsible for payment at the time of service. *

We accept HSA/FSA card payments, and provide superbills for patients to request reimbursement from their health insurance provider. Patients are responsible for payment at the time of appointment. Choulet Wellness has no control over whether or not a health insurance plan will cover appointment costs. Please call our clinic if you would like more information

I understand

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