Contact Form
Please complete the form. Our team will contact you soon.
Submission Date/Time
*
/
Month
/
Day
Year
Hour Minutes
AM
PM
AM/PM Option
Who are you?
*
Patient (or relative of patient)
Pharmacy
Other
What kind of patient are you?
*
New Patient
Existing Patient
Are you contacting about our special services?
*
TMS Treatment
Spravato Treatment
Neither
What do you need assistance with?
*
Appointment/Scheduling
Medication
Billing
Insurance
Request Information
Technical Support
Other
For direct assistance, please contact our billing department directly:
631-229-9902
Patient Name
*
First Name
Last Name
Patient DOB
*
/
Month
/
Day
Year
Patient's Provider
*
Patient Name (if applicable)
First Name
Last Name
Patient's Doctor (if applicable)
Back
Next
Contact Details
So our team can respond to you.
Your Name
*
First Name
Last Name
Contact Phone
*
Contact Email
*
Company Name (if applicable)
Fax Number (if applicable)
What can we help you with?
*
Please verify that you are human
*
Submit
Should be Empty: