We are excited about the possibility of working together! Your completion of this convenient, secure multi-page form will give us the information we need to start the intake process. We will contact you within one business day (usually sooner!) of your form submission to discuss scheduling and, if applicable, give you a quote of benefits from your insurance company.
You may find it easiest to complete this form on your smart phone as photos of your insurance card are required on a subsequent page, if you plan to pay at least partially with insurance.