Contact Information & Communication Consent

Please correct the errors described below.

1. What's your appointment preference?

Date of Birth

My preferred communication is:

Provider Request:


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.

AVAILABILITY NOTICE: Due to the high volume of requests and COVID-related factors, we're only able to respond if we can accept you as a new patient. Currently, both providers are full. We'll update this form as the availability status changes. We anticipate we will reopen to intakes in January 2021. However, we encourage you to complete this form if you believe we're a good fit for you!

Your information will be encrypted.