Appointment Request Form
Please fill out the form and a representative from the practice will reach out to confirm this appointment with you.
Email address *
Appointment Type: Physician Prompt
- We take extra effort to accommodate your appointment as quickly as possible, generally within 1-2 weeks.
- Initial Visit + 3 month support ($1395)
- $100 discount applies when forms are received prior to visit
- $200 non-refundable deposit is required to book the Prompt Appointment.
Appointment Type: Physician Standard
- Implies that we provide an appointment based on availability.
- Initial Visit + 3 month support ($1175).
- $100 discount applies when forms are received prior to visit.
- $200 non-refundable deposit is required to book the Standard Appointment.
Appointment Type: Physician Supervised
- NOTE: Not the same as Physician Appointment.
- For more information please visit Physician-Supervised on our website.
- Initial Visit 90 Minutes ($695).
- $100 discount applies when forms are received prior to visit.
- $100 nonrefundable deposit is required to book the Physician-Supervised Appointment.
What type of appointment are you requesting?
Were you referred by a healthcare provider?
If yes, who referred you?
Your answer
Your name or nickname
Your answer
Your age
Your answer
Your gender
Do you plan to use insurance for some services?
Your phone number
Your answer
Best time to call you?
Your answer
Preferred day of the week?
Preferred time of day?
Do you want an early morning (before 8:30am), after hours(after 5pm) or Saturday appointment?
If we could accommodate an appointment in the early morning, after hours, or on Saturday, are you willing to pay an extra $100?
How quickly do you need to be seen?
Your answer
Reason for your visit or additional comments (optional):
Your answer
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