Schedule an Appointment Schedule an Appointment Schedule an Appointment Name * First Name Last Name Email * Phone * Please include your number in the format below xxx-xxx-xxxx (###) ### #### Insurance/Provider * Date of Birth * Please include your date of birth MM DD YYYY Checkbox * Please include what type of treatment your looking for For Pain For Rejuvenation Message * City, State, Zip * Emergency Contact xxx-xxx-xxxx (###) ### #### Medical History * Include information of Current Medications, Allergies, Past Illnesses & Surgeries, Famly Medical Hisotrym Cheif Complaint & Reason for Visist. Consent & Acknowledgements Coonsenset Statements Authorization to release medical information to my insurance company for billing purposes. Acknowledgement of financial responsibility for copays, deductibles, and any amounts not covered by my insurence. HIPAA privacy notice acknowledgment - I have received and reviewed the HIPAA privacy notice. Thank you!
