New Patients

Please note that we primarily offer medication management services. We do not have a clinician who can provide therapy or counseling services.

Additionally, we cannot accept individuals with a Medicare or Medicaid plan as a primary or secondary plan since we are not credentialed with any of those plans.

Please provide us with the following information. After we review this form, we will contact you by email with a few screening questions to gather some additional necessary information. We typically respond within 1 business day, but it may take up to 2 business days.

Name

First Name

Last Name

Pronouns

Date of Birth

MM

DD

YYYY

Age

Email Address

Phone

cell/mobile preferred

(###)

###

####

How did you find us?

If you were referred by an individual or a business/practice, please provide their name:

What health insurance do you have?

Submitting this form does not create a provider-patient relationship. Kindly check the box below to acknowledge this statement.

I confirm that I have read, understood, and provided accurate answers to the best of my knowledge.