Consultation Request

Consultation Request

This form helps prospective new patients and clinicians connect more efficiently and explore whether the requested relationship will be a good fit. Please complete the following form with a good phone number. Someone from the office will be in touch within 72 hours of the consultation request to discuss goodness of fit and next steps for scheduling.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.
This request is not an emergency or urgent matter. I wish to proceed.*

Yes

Clinical Information

Please tell us about the person for whom treatment is being requested.
Name*

First NameLast Name
Email*
example@example.com
Gender*
Date of Birth*
My relationship to the patient. *
My Phone Number*
Please enter a valid phone number. *
How were you referred to Reset Health & Wellness?*
I understand I must be physically located in the state of North Carolina for appointments (conducted either in person in Raleigh, NC or virtually located in the state of NC).*

YesNo
I agree to communication with Reset by email and/or phone/text.*

YesNo

Payment Information

Elizabeth Cox, MD does not participate in insurance plans.
I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible. I understand that Dr Cox is opted out of Medicare and I will not be eligible for reimbursement if I have Medicare insurance.

YesNo
Should be Empty:

Clinical Information