Secure Contact Form

Please correct the errors described below.

Client First and Last Name

Client Date of Birth

Your Name if Different From the Client

Email Address

Best Contact Number

By entering your phone number, you agree to receive informational SMS messages (appointment reminders, account notifications, etc.) from us. Message frequency varies. Message and data rates may apply. for help, reply HELP or email us at (company general email address). You can opt out at any time by replying STOP.

What is your insurance? Please select the option that best applies to you.

We take Blue Cross Blue Shield, HealthPartners, Midlands Choice (Cigna), Aplos, United Healthcare, and Self-Pay. There are also options for superbilling to out of network insurances.

Do you prefer telehealth or in-person appointments?

Telehealth

In-Person

No Preference

Preferred Appointment Day (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Appointment Time (check all that apply)

Morning

Afternoon

Evening

No Preference

What is the presenting issue that brings you in?

Any additional comments or requests?

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide