Request An Appointment
This form must be completed before we can schedule your appointment. Please complete all information as accurately as possible to ensure we can best meet your satisfaction.
- Currently, we do not provide services in the following states: Alaska, Hawaii, Louisiana, Massachusetts, Mississippi, North Carolina, Rhode Island, and South Dakota.
- Please note, we CANNOT prescribe narcotics, or controlled substances.
Notice: Currently, we cannot provide services in the following states: Alaska, Hawaii, Louisiana, Massachusetts, Mississippi, North Carolina, and South Dakota.
I acknowledge that the information above and attached is complete and accurate.
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