Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

This helps us confirm that you live in North Carolina.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Notes on Insurance *

I understand that we cannot accept patients who have Medicare.

I have reviewed the FAQs webpage and understand that we do not accept insurance. However, we are able to provide invoices for you to submit to your insurance provider for out-of-network claims, which may result in partial reimbursement for our services.