First Name
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Last Name
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Email
example@example.com
Phone
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How Can We Help You?
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General/Marketing/Services Questions
Scheduling Question
Payment Method:
Self-Pay ($250.00 for new patients)
Insurance
Note: You will not be charged right now.
Policy Name
(Only plans we accept)
*
Cigna
Bright Health
Carolina Behavioral Health Alliance
Blue Cross Blue Shield
(Blue Advantage, Blue Options, State Health Plan, Blue Care, Blue Select, Blue Home-Novant Health, Classic Blue)
Policy #
Date of Birth
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Month
-
Day
Year
Date
Message
How did you hear about us?
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