New Patient

For all consultation appointments, we collect a deposit of $175 which is the total cost of the consultation exam. This is to hold your place on our schedule. This deposit will cover your exam fee only. It does not cover any pre-anesthetic screening costs (i.e. bloodwork), medication, or procedure costs. We understand that scheduling conflicts occur, but should you be unable to make your appointment for any reason, we require at least 72 hours (3 business days) cancellation notice by email or phone. This allows an adequate amount of time to offer an open appointment slot to patients on our waitlist. We reserve the right to keep the collected consultation deposit of $175 if your consultation exam is not cancelled or rescheduled at least 72 hours prior to the scheduled consultation exam date.

New Patient Form

    Client Info

    standard messaging rates apply

    standard messaging rates apply

    standard messaging rates apply

    Patient Info

    Patient Medical Info

    *Accepted files: .png, .jpg, .gif
    Max file size: 6MB.



    Payment is due at the time services are rendered. A deposit may be required at the time of scheduling a treatment procedure. Payment may be made by cash, check, accepted credit cards, or pre-authorized payment services (Care Credit). Please advise us in advance if you have any questions or concerns regarding our payment policy.

    By signing this document, I ackowledge that I (the owner or agent) am financially responsible for all charges related to documented patient(s) on my record, and I understand the hospital's financial policy. I also acknowledge that the above information and statements are accurate.

    My name typed in the box below will be accepted as a legal electronic signature