I'm honored to work with you! And look forward to our first appointment.
Please fill in this form.
If a question doesn't apply leave it blank.
There are a few questions that do require a response. They must be completed to submit the questionnaire.
Your answers are confidential because the responses are embedded in this HIPAA-compliant intake and will be recorded in your secure HIPPA-compliant patient portal.
Once you submit the form you'll receive an invitation to create your patient portal, appointment reminders, and a link to the video chat room via email.
Please submit your intake no later than 24-hours before your appointment. Otherwise, we will have to reschedule.
See you in the video chat room!