Be Seen Inquiry & Wellness Request Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Provider Preference?
*
NP Latonya Sultzer
NP Simyon Taylor-Hayes
First Available
Unsure
For patient who have a current established relationship with one of the listed providers. (What do you need help with)? Or if interested in End of life support or Career Navigation
Follow-up care
Medication / refill
Lab results
Injections / wellness
other
End of Life Support
Career Navigation/ or / Care Coordination & Support Services
Services Interested in
Please Select
Wellness Injections
Medical Weight management
Botox/ Fillers
DOT
Physicals
Acute visit/ Sick Visits
Primary Care Services
Women's Health Services
Healthcare Consulting/ Organizational Services
Unsure/ Need Guidance
Do you plan to use insurance?
Yes
No
Not sure
If yes: What insurance?
Preferred contact method (choose 1 or 2 options)
*
Call
Text
Email
I agree to be contacted by Be Seen, LLC regarding my inquiry. I understand that I may revoke this consent at any time by notifying Be Seen, LLC in writing by phone at 317-779-7000 or by email at care@beseeneveryday.com. Revoking consent will not affect any care I have already received.
*
Yes
How did you hear about Be Seen, LLC
Please Select
Women's Wellness Expo
Social media
Friend or family referral
Google search
Existing patient referral
Patient from another entity and looking to transfer care
Other
PAYMENT ACKNOWLEDGMENT By selecting your injectable service(s) above and submitting payment, you authorize Be Seen, LLC to charge your card for the selected injection(s). Payment is due at time of booking. All sales are final. No refunds will be issued for services rendered. If you need to cancel or reschedule please contact us at least 24 hours in advance at care@beseeneveryday.com or 317-779-7000. Be Seen, LLC reserves the right to decline service if clinically inappropriate.
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