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New Patient Intake Form

Please complete the form below to request an appointment. Our office will review your request and contact you regarding scheduling, insurance verification, and patient portal access. If appropriate for our practice, you will receive secure patient portal access to complete intake forms and provide additional information prior to scheduling confirmation

First Name

Last Name

Email

Phone Number

Reason for visit

Are you planning to use insurance or self-pay? Self-pay price is $50.00

Are you planning to use insurance or self-pay? Self-pay price is $50.00
A
B

If insurance, which insurance carrier do you have?

By signing this form, I acknowledge that telehealth services may have limitations compared to in-person medical evaluation and that I may be referred for in-person evaluation if clinically necessary.

Signature