Consultation Request
Our office will respond within two business days
Full Name
*
First Name
Last Name
Phone Number
*
By providing your phone number, you authorize us to call, message, or send SMS notifications regarding your medical care and billing matters.
Email
*
By providing your email address, you authorize us to email you regarding your medical care and billing matters.
Preferred method of contact
*
Phone
Email
Reason for Consultation (select all that apply)
*
Mental Health Evaluation
ADHD Testing & Evaluation
Ketamine Therapy
Medication Management
Pharmacogenetic (PGx) Testing
Hormone Replacement Therapy
Advanced Lab Testing
Medical Weight Loss
IV Hydration Therapy
Wellness Injections
Peptide Therapy (HGH)
Botox
Other
Scheduling for yourself or other? (if other, please indicate relationship)
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Self
Other
Do you plan on using insurance?
*
Yes
No
Primary Insurance
Please Select
Aetna
Anthem BCBS
Blue Cross Blue Shield
Carelon BCBS
Commonwealth Care Alliance
Cigna (Evernorth)
ComPsych
First Health
Global Benefits Group
Harvard Pilgrim
Health Plans Inc.
Mass General Brigham (commercial only)
Medicare
MediNcrease
Multiplan
Surest (formerly Bind)
Tricare
Tufts Health (Commercial)
Tufts Health Direct (Connector Care)
United Healthcare
United Medical Resources (UMR)
Secondary Insurance
Enter name of insurance carrier
Additional Information
Enter any pertinent information you would like to share / List preferred consultation dates & times in order of preference
Select best date & time for callback
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