Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you! Our practice is focused on providing high quality, patient-centered care, because of our care model, we do not accept health or vision insurances. We absolutely want to care for you and your family, and so we keep our fees reasonable and competitive. We do accept HSA, FSA, and we offer easy financing through Sunbit. We also do accept auto accident and workman’s compensation. Please contact us and we would be happy to answer any questions you may have. NamePhone*Email* Preferred Date* Date Format: MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningNature of VisitCAPTCHACommentsThis field is for validation purposes and should be left unchanged.