Request an Appointment or Consultation

Request an Appointment or Consultation

Please fill out the form below to join to request an appointment or consultation with our practice. We will contact you as soon as possible!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How can we help you?*
When / how would you like us to contact you?
Program Options

Membership Program	Standard Program
A simple monthly membership providing unlimited visits, routine services, and convenient virtual access. Care is predictable, comprehensive, and centered on long-term patient health.	Straightforward, pay-per-visit primary care. Patients pay only for services received, offering flexibility and control without membership commitments while still ensuring personalized, high-quality medical care.
Insurance Not Required	Insurance Accepted: - Aetna (HMO / PPO / Medicare Adv) - Anthem (PPO / Medicare Adv) - United (HMO / PPO / Medicare Adv)
Status: [Accepting Patients]	Status: [Accepting Patients]

Which Program(s) are you interested in?*

Membership ProgramStandard Fee For Service
Do you have Medicaid or Traditional Medicare as Primary or Secondary Insurance?*
Thank you for your interest in Starlight Health,

However we are not currently accepting new patients with Traditional Medicare or Medicaid plans

- Starlight Health Team
What Primary insurance do you have? If you do not see yours listed please select self pay*

Self PayAetna (HMO)Aetna (PPO)Aetna (Medicare Adv)Anthem (PPO)Anthem (Medicare Adv)United (HMO)United (PPO)United (Medicare Adv)
Insurance Group #
(If Applicable)
Insurance Member #*
What Secondary insurance do you have? If you do not see yours listed please select self pay*

Self PayAetna (HMO)Aetna (PPO)Aetna (Medicare Adv)Anthem (PPO)Anthem (Medicare Adv)United (HMO)United (PPO)United (Medicare Adv)
Secondary Insurance Group #
(If Applicable)
Secondary Insurance Member #*
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Program Options