Name *

First Name

Last Name

Date of Birth *

necessary for chart creation

MM

DD

YYYY

Gender *

Male

Female

Cellphone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Policies and Fees Acknowledgement *

I HAVE REVIEWED AND AGREE WITH YOUR POLICIES AND FEES. I UNDERSTAND YOUR PRACTICE DOES NOT ACCEPT INSURANCE AND AGREE TO YOUR FEES. *

Yes

Correspondence Acknowledgement *

Upon receipt of your Consultation Request, we will establish your electronic medical record and email you instructions. Please check your email, you will not receive a phone call!

I understand