Shermin Davis Appointment Request Form
Date of Birth
Dates, Days and/or Times that work for you
Meeting Options (check all that you are interested in)
Face to Face Online
Other / Out Of Network - please specify below
No Insurance - I'll pay privately
Other Insurance Info
Insurance ID #
Type NA if paying privately
** PLEASE NOTE: At the moment this office is not able to accept/file insurance. Please check the option that applies for you below.
I want to be notified and schedule an appointment when my insurance can be utilized
I want an appointment earlier and will pay privately until my insurance can be utilized
Should be Empty:
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