• Captcha Field

Consumer Assistance Application

Please complete the following confidential intake application

to the best of your ability.

If you have any questions, comments or concerns, please contact a member of the clinic staff & someone will be glad to assist you.

You can reach out with our Contact Card

by clicking (here) to be redirected to our Home Page.

***By Agreeing to Our Services, this means you have read and agree to our Consumer Policy listed at bottom/footer of website or is available by (clicking here).