Contact Information & Communication Consent

Please correct the errors described below.

1. Hello! Let's get started!

Date of Birth

My preferred communication is:

Provider Request:

Payment Request:

*If using your insurance, please include a picture of the front side of your card.

    Please upload a file


    We use HIPAA-compliant technology to reduce wait times, improve the intake process, and ensure that you have access to your provider when needed. We need your consent in order to move forward. Your provider will explain each service in detail.

    Your information will be encrypted.