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Let Us Connect You with the Right Care

Please take a moment to fill out the form.

Service Interest & Treatment Goals

Which specialty are you interested in?
Filter items with What are your treatment goals? (Check all that applies) Required

Preferred Location & Time of Day/ Urgency

Preferred cities for treatment. (Check all that applies) Required

Payment Preferences

How do you plan to pay for care?

(Please note: Our providers primarily work with cash-pay patients, but some may accept insurance. Please select the option that applies to you.)

Are you aware that some providers may not accept insurance, and care may require out-of-pocket payment?

Verification

Are you ready to schedule an appointment if matched with the right provider?
How Did You Hear About Us?

Informed Authorization

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*Your information is secure and will only be shared with trusted healthcare providers to address your care needs. We do not sell or misuse your personal information.*​

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