Personal Injury New Patient Appointment Request

NON-ATTORNEY HANDLED CASES ONLY

Includes:

1st visit: Consultation, examination, digital x-rays (if needed)

2nd visit: Doctor's report of findings

You will be responsible for your first visit charges until we are able to verify benefits with the insurance company.

Once this is confirmed, your payment(s) will be refunded.

No-show/late cancellation/missing paperwork charges are non-refundable.

$49 deposit required in order to book

*does not include an adjustment

*not valid with Medicare

PLEASE COMPLETE YOUR INFO BELOW
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