Name *

First Name

Last Name

Phone *

(###)

###

####

Please select all that apply. *

Seeking care for myself

Seeking care for a family/friend

Seeking care for a minor

I've been in an auto accident with-in the past 2yrs

I am over 65

I have Medicare

I have Medicare and an Advantage plan

We are an out of network providor. *

By selecting YES, you acknowledge that you have read and understand that we are an out-of-network provider with all major medical insurance plans. We operate as a cash-based practice, however we do bill Medicare part B and Auto Insurance policies following a collision.

Yes, I understand that this is a cash-based practice.