SCHEDULE YOUR APPOINTMENT

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Telehealth Appointment*

VideoPhone

Appointment*

Please Note**

By scheduling this appointment you are expected to pay for services before and/or at the beginning of any session/service provided.

By scheduling this appoointment and using insurance I understand and agree that it is my responsibility to know if my insurance has any deductible, copayment, co-insurance, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for the services I receive and I agree to make payment in full.

If your account has a balance that has not been paid, and no other agreement has been made at the time the balance is due your appointment may be canceled.