Intake Form

after booking AN INITIAL NEW PATIENT APPOINTMENT FROM THE HOME PAGE — PLEASE complete THE FOLLOWING intake form

All information entered in this form is confidential. Once you click Submit, the form is sent to a HIPAA-compliant portal and is read only by practitioner.

Instructions: Required fields are asterisked *. You may skip any and all questions that do not apply. After completing a section click "Next" to continue (you may need to scroll up to find the next section on your computer or phone). After the last page Mandatory Disclosure, please type your name and click "Submit."