Request an Appointment Please fill out this form and we will contact you about scheduling. Name * First Name Last Name Phone * (###) ### #### Email * Current Patient? * Yes No Preferred time of day? * Mornings Midday Afternoons Anytime Preferred day of the week? * Monday Tuesday Wednesday Thursday Friday No preference Specific day and time request? Do you plan to self-pay? * Yes No Would you like a superbill to seek out reimbursement from your insurance company? Yes No Do you plan to have us bill your insurances? * Yes No If so, what is your insurance plan name? Medicare Humboldt IPA TriWest Work Comp Other Message: Thank you!
